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Potential complications of high-frequency oscillatory ventilation (HFOV) include hemodynamic compromise, barotrauma, inadequate humidification, endotracheal (ET) tube obstruction, and intraventricular hemorrhage in the neonate.
Asymmetric chest rise may indicate a pneumothorax.
Several modes of high-frequency ventilation (HFV) are available. Modes are described by the delivery method and classified by the exhalation mechanism (active or passive). HFOV is the most commonly used mode of HFV.
HFOV delivers a smaller tidal volume (VT) than conventional ventilation, usually less than or equal to the anatomic dead space volume. This decreased VT decreases barotrauma and allows for healing of the lung tissue. With HFOV, oxygenation and elimination of carbon dioxide occur as long as the lung is inflated.4 Alveolar recruitment continues for several hours after HFOV therapy begins, and arterial partial pressure of carbon dioxide (PaCO2) values may initially climb.
Clinical indications for HFOV include:
HFOV is used in the treatment of acute lung injury and acute respiratory distress. The goal of HFOV is to provide respiratory support while avoiding the alveoli stretching and barotrauma that occurs with conventional ventilation. HFOV provides lung protection to children with deteriorating gas exchange who require increased ventilatory support.
Essential terms include:
Potential complications of HFOV include:
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Rationale: Monitoring indicates the adequacy of ventilation and signs and symptoms of complications and allows the nurse to respond immediately to changes in carbon dioxide and oxygenation levels.
Rationale: Analgesia, sedation, and neuromuscular blockade should be adjusted to adequate levels before the start of HFOV.
Administer the minimal dose of paralytic agent necessary to achieve the desired effect.
Rationale: Proper function of the ventilator must be demonstrated before initiation.
Watch for a green light-emitting diode (LED), which signifies that the oscillator is enabled.
Rationale: Bias flow provides fresh gas to the circuit and enhances carbon dioxide clearance. Bias flow works interchangeably with the mPaw; the knob should be adjusted to establish the set mPaw.
Readjust the mPaw after changes in bias flow to prevent inadequate or impeded clearance.
Rationale: If the bias flow is less than the oscillatory flow, carbon dioxide clearance will be inadequate, reducing the ventilation effect while increasing the pressure differential to high levels (amplitude). If bias flow is greater than oscillatory flow, carbon dioxide clearance may be impeded.
Rationale: The goal is maximum alveolar recruitment without overdistention of the lungs. The mPaw is adjusted to maintain optimal lung volume. The mPaw can fluctuate with temperature and humidity changes. Lung volumes reach equilibrium slowly in response to changes in ventilator pressure.
Rationale: Frequency is the secondary control for ventilation, and it depends on the child’s weight.
Frequency usually needs no adjustment after the rate has been established.
Rationale: Frequency is not weaned as in conventional ventilation. A decrease in frequency causes an increase in volume displacement, which would decrease the Pa
2 level. Too high a frequency may cause an elevated Pa
2 because of small volume displacement (less than anatomic dead space).
Rationale: Adjusting the power control changes the piston displacement, which in turn affects the amplitude. Amplitude is the primary control for ventilation.
Look for an adequate chest wiggle to establish the appropriate amplitude.
Rationale: Attenuation varies according to the size of the ET tube.
Rationale: Using an I:E ratio of 1:2 has been shown to minimize the risk of air trapping.
Rationale: Adjusting the F
2 to the lowest possible level is the goal of therapy. Permissive hypoxemia may be acceptable in some children with certain conditions.
The inability to wean FIO2 after stable ventilator settings have been established may indicate poor lung expansion or HFOV failure.
Rationale: The use of heat and humidity with mechanical ventilation is necessary to prevent damage to the mucosa of the respiratory system. Adequate humidification keeps secretions from becoming thick and sticky.
Rationale: Ventilator alarms protect the child from injury and prevent equipment damage.
Set pulse oximeter alarms at a narrow range.
Rationale: Loss of pressure in the circuit causes an audible and visual alarm.
Rationale: Proper positioning reduces the risk of skin breakdown from immobilization and promotes airway stability.
Rationale: Reviewing chest radiographs assists in the evaluation of lung volume. Inadequate lung volume inhibits optimal gas exchange.
Reportable condition: Inadequate lung volume as evidenced by chest radiograph
Rationale: Maintaining appropriate ventilator support assists in the evaluation of lung volume.
Reportable condition: Significant changes in mPaw
Rationale: Evaluation of chest wiggle alerts the nurse or respiratory therapist to changes in the child’s lung compliance. Changes in chest wiggle may indicate mucus plugging, dislocation of the ET tube, or pneumothorax.
Reportable condition: Significant changes in chest wiggle
Rationale: The child is especially at risk for hypotension when mPaw is high and hypovolemia or cardiac dysfunction is present.
Reportable conditions: Tachycardia; hypotension; poor perfusion, including cool extremities and changes in skin color
Rationale: Changes in the symmetry of the chest or intensity of the piston could indicate changes in lung compliance, mucus plugging, ET tube dislodgment, or pneumothorax.
Reportable conditions: Tachycardia, increased work of breathing, cyanosis, asymmetric chest movement, decreased SpO2 level, significant change in breath sounds, significant change in intensity of piston
Rationale: The ABG analysis provides quantitative measurements of carbon dioxide and oxygen levels.
Reportable condition: Significant changes from previous ABG levels
Rationale: Noninvasive monitoring provides continuous evaluation of oxygenation and ventilation. Weaning the F
2 is often based on the Sp
Reportable condition: Significant changes in TcCO2 and SpO2
Rationale: Inline suctioning (without breaking into the circuit to cause derecruitment) establishes airway patency, ET tube patency, and lung recruitment and removes secretions.
Do not disconnect the child from the HFOV to perform open suctioning.
Reportable conditions: Inability to clear secretions, deteriorating respiratory status
Rationale: Children are at risk for developing skin breakdown from immobilization.
Reportable condition: Breakdown of skin integrity
Rationale: Adequate humidification is necessary to prevent mucosal damage. Inadequate humidification can cause problems with mucus plugging and decreased chest wiggle, which decrease ventilation.
Reportable condition: Mucus plugs that result in decreased ventilation
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