Canberra Hospital and Health Services Clinical



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Purpose

This section outlines the process of the open method of endotracheal tube (ETT) suctioning. It is performed to remove tracheal secretions, maintain a clear airway or when obtaining secretions for pathology testing .Open suction may be required when inline suction has not effectively removed secretions


Equipment

  • Alcohol based hand rub (ABHR)

  • Suction catheters (size 6 or 8, depending on size of ET tube)

  • Sterile gloves


Procedure

  1. Collect equipment

  2. Obtain help from a second RN/M

  3. Ensure oxygenation is monitored by pulse oximetery

  4. Open suction catheters

  5. Don sterile gloves

  6. Ensure oxygenation is monitored by pulse oximetery

  7. Check suction pressure by occluding tubing – pressure should be 10 -15kps

  8. The required depth for insertion of the suction catheter is the length of the ETT plus the length of the connector

  9. Remove suction catheter from packet, taking care not to contaminate and connect suction catheter to the suction tubing

  10. Ask the assistant to disconnect the ventilator from the endotracheal tube

  11. Without applying suction, insert the catheter to the predetermined length, whilst the assistant supports the endotracheal tube and restrains the infant’s head

  12. Apply suction by occluding the “Y” connection and withdraw slowly checking disconnection from the ventilator does not exceed ten seconds - minimising hypoxia

  13. Observe secretions at the ‘Y’ connection

  14. Reconnect the ventilator to the endotracheal tube

  15. Repeat the suctioning steps two more times if required or until the endotracheal tube is clear - taking into account the patient’s tolerance to the procedure

  16. Replace suction catheter with either size 8Fg or larger according to patient size

  17. Re- check suction pressure is 10 - 15 Kpa

  18. Suction the mouth

  19. Auscultate the chest to ensure that suctioning has cleared the secretions

  20. Clear the suction tubing with normal saline

  21. Turn off the suction

  22. Settle the infant

  23. Document the amount and characteristics of the secretions, and the patient’s tolerance to the procedure on the flow chart

  24. The aspiration of any plugs, blood stained or yellow secretions, difficulty in inserting or inability to insert the suction catheter to the predetermined depth or deterioration of the infant during and/or after the procedure must be reported to the Team Leader and/or Medical Officer

  25. Minimise episodes of suctioning in order to maintain PEEP to decrease the risk of pulmonary haemorrhage

  26. Dispose of used equipment


Outcome

  • The infant has a clear airway as evidenced by clear bilateral breath sounds


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Section 9 - High Frequency Ventilation



Purpose

The purpose of Section 9 is to outline the equipment required and the process by which the parameters for High Frequency Oscillation Ventilation (HFOV) are set.


HFOV uses tidal volumes that may be less than or equal to the anatomical dead space volume. It produces adequate gaseous exchange at lower peak airway pressures theoretically reducing the risk of barotrauma. Breaths are delivered by a vibrating diaphragm for both positive inspiration and active exhalation.
The Leoni ventilator is used to deliver HFOV


Differences

Conventional

HFOV

Respiratory rates

0-150/min

180-900/min

Tidal volume

4-20ml/kg

0.1-3ml/kg

Alveolar pressure

0-50cm H2O

0.1-5cm H2O

End expiratory volume

Low

Normalised

Gas flow

Low

High


Indications

  • Severe lung disease that is unresponsive to conventional ventilation - “rescue therapy”

  • Pulmonary air leaks, pulmonary interstitial emphysema, pneumothorax, bronchopleural fistulas, and pneumopericardium

  • Hypoplastic lung, diaphragmatic hernia

  • Persistent Pulmonary Hypertension (PPHN) of the newborn, meconium aspiration


Equipment

  • Ventilator Circuit

  • Ventilator Circuit non-disposable

  • Leoni Ventilator

  • Humidifier base/chamber

  • Water for injection

  • Grey Wire – short

  • Grey wire – long

  • In-line suction apparatus


Background

  • HFOV has been described as CPAP with ‘wobble” or ‘wiggle” (Figure 1). The components of HFOV include:

  • Mean airway pressure (CPAP) – recruitment and sustained inflation of alveoli (MAP) controls O2

  • Frequency and amplitude (wobble) – of the waveform imposed onto the CPAP controls CO2



Using HFOV in the clinical setting:

  • Ensure appropriate size ETT(minimal Leak)

  • Commence transcutaneous PO2 and PCO2 monitoring as well as invasive BP monitoring if possible

  • Optimise systemic blood flow (Volume bolus, Inotropes)

  • Optimal analgesia, sedation

  • Lung recruitment manoeuvre should only be performed with a Fellow or Consultant present.


Select settings for HFV:

  • Mean Airway Pressure (MAP) – This is selected using mean pressure (P mean) on HFO mode. Set P mean at 2 cm H2O above P mean on conventional ventilation. Increase P mean in steps of 1-2 cm/H2O every 5-10 minutes (may be longer in certain conditions like MAS or BPD). When SPO2>94% lower Fi02 in steps of 5-10%.

  • Continue recruitment until Fi02< 30% or no improvement in saturations after 3 steps (this is the recruitment strategy).

  • Decrease P mean in steps of 1cm H2Oevery 2-3 minutes until saturations deteriorate at a constant Fi02 (<30%). This is the closing pressure. At this point re-recruit and drop the pressure back to 2cm H20 above the closing pressure. Maximum pressures that have been used are 25cm H20. Arrange for a chest X-ray once blood gases are stable (usually 1-2 hours later). It is useful to conceptualise HFOV as ventilating the lung around one sustained pressure volume hysteresis loop (Figure 2)


ALERT

Due to the risks of hypercarbia strongly consider transcutaneous PO2 and PCO2 monitoring





Point A:

Underinflated with high oxygen requirements

Point B:

Well inflated. The lung has ‘opened up’. Good chest wobble. Fi02 stats to decrease. Any further rise in pressure results in little extra volume recruitment

Point C:

Overinflated Fi02 may remain unchanged for a while. Chest wobble decreases. CXR determination >9 posterior ribs

Point D:

Ventilation on the expiratory limb, achieving maximum inflations with minimal pressure.

Amplitude (wobble)

start at twice the MAP and watch the chest wobble. Watch the TcCO2 or measure blood gases to establish adequate amplitude. A higher amplitude will lower the CO2.

Frequency strategies

as per strategies listed below based on lung pathology. As a general rule, a frequency of 10 Hz is a good starting point in both preterm and term infants.

Leoni ventilator: Start up and initiation


Process

Follow the steps below to comment HFOV




1

Attach

  • HFV filter to ventilator circuit as per figure 1

2

Select

  • HFO on ventilator screen

3

  • Adjust Hz, amplitude and PEEP see diagram below

4

  • For sigh breaths set ‘Freq (Rec)’ to desired setting

5

6

Commence treatment.

  • Press start

7

Once settings established reset alarm limits

8

  • Observe infant for chest wiggle

9

  • Set humidity temperature 40o C – 3o C
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