The VDR is a flow interrupting jet ventilator that runs over top of pressure control ventilation
Patients that might benefits from the VDR
Copious secretions
Unilateral lung issues with wide differences in compliance
Possible asthmatics requiring intubation
Pt requiring more than q3 IPV treatments
Keep a backup phasitron at bedside
Oxygen analyzer now placed in the green line, but two filters are still required for the red pressure line
Please fill in the log book any information you would like to share, i.e.: dropped CR by keeping Ti the same and lengthening the CR Te, pre and post gasses
Knobs
Controls on Front Face Panel
Pulsatile Flowrate
Determines the amplitude or peak inspiratory pressure (PIP) delivered to the patient during inspiratory time
Inspiratory Time
Selects the time from 0.5 seconds to 5 seconds that volumes are delivered to what PIP is determined by the Pulsatile Flowrate control
Expiratory Time
Selects the time from 0.5 seconds to 5 seconds that PIP is not being delivered
Programmed for Oscillatory/Demand CPAP/PEEP or a static baseline
Oscillatory CPAP/PEEP
Provides a baseline pressure during the expiratory phase
Demand CPAP/PEEP
Provides for the establishment of “static PEEP” that automatically increases flow to the patient as the inspiratory demand warrants
Convective Pressure Rise
Programmed to occur 1 second into the inspiratory phase when activated
Controls the pressure rise above the PIP
Use with caution and when low compliance requires very high delivery pressures
Pulse i/e Ratio
Controls the i/e ratio of the pulse frequency volumes are delivered
Pulse Frequency
Controls the rate of the high frequency, volumes delivered (percussive rate)
Reset Alert
Reset Alarm Circuit
Nebulization
Controls the flow of gas to the aerosol circuit
Manual Inspiration
Deliver a regulated source of gas through the orifice of the Phasitron Venturi
The longer the button is held, the greater the potential for tidal volume delivery
Master On/Off
Activates unit when placed into the on position
When in the off position, the Manual Inspiration, Nebulization, Demand CPAP/Peep are still functional for weaning purposes
Failsafe Sensitivity
Limits a maximum sustained pressure over a programmed time
Controls on Top of the Panel
Operating Pressure Control
Controls the peak operating pressure of the entire machine
At maximum output it will only provide pressure slightly less than that of the institution
Optimal pressure is 50 psi
FiO2
Allows selection of oxygen concentrations from 21% to 99+ %
Multimeter
The pressure monitoring source we match to the orders and chart (Not the Monitron)
The pressures the multimeter give you are an average of the two pressure spikes on the Monitron during the convective inspiratory phase and an average of the two pressure spikes during the convective expiratory phase
Nebulized ½ Normal Saline
We nebulize ½ NS at 12ml/hr for humidity because sterile water doesn’t nebulize well
Complications must we watch for
Salt crystals in the circuit
Entrainment and Expiratory Valves
Need to be at a horizontal position on the phasitron at all time
There is a bias flow of 25Lpm that might be forced into the patient if the valve is occluded
The expiratory valve is the last available flow source for the patient if peak inspiratory flow exceeds the ventilators capabilities
Maintaining the cuff while on VDR
Minimal occlusion pressure unless high vent settings required
If there are high vent settings, then an order for a fill volume that gives a minimal leak is needed
Reduce Accidental Extubation Guidelines
An optional omniflex may be used between the Aerogen and inline suction to reduce accidental extubations due to limited mobility of the VDR circuit
Use vent arms, towels, positioning pads, etc. to position the phasitron level with the patients head
Re-Tape ett Q24
Charting
Chart all four pulse points under vent comments
Chart bleed-in of Nitric, if on Nitric, in addition to standard nitric charting
80ppm/4lpm bleed-in, under specialty gas comments
Cuffs inflated via minimal occlusion practice, unless otherwise ordered by fill volume or deflated
O-cpap to be charted under total cpap. If demand cpap ordered, demand cpap under o-cpap and then o-cpap under total cpap
example
order of a demand cpap of 4, with a ocpap 12
Chart o-cpap of 4 and total cpap of 12
Multimeter should read 12.
Calculating Total Cycle Time
60/Convective Rate = Total cycle time
If you wanted a convective rate of 20
60/20 = 3 TCT
TCT / I:E ratio parts = inspiratory time in seconds
Wanted I:E of 1:3 with a rate of 20
1 + 3 = 4
TCT/4= insp time in seconds
3 TCT / 4 parts = 0.75 insp time in seconds
TCT – insp time = exp time in seconds
3 - 0.75 = 2.25 exp time in seconds
1:3 I:E with a rate of 20 = .075 seconds (1 part) : 2.25 seconds (3 parts)
Settings
Starting Settings
Pulsatile flow equal to PIP from conventional(multimeter)
Convective rate to patients size, take note of needed i-time and expiratory tidal volume/kg
Infant: 25-30
Pedi: 20-25
Adult : 12-16
BIG I:E 1:1 to start
O-cpap 8-10 or 2 higher if currently >8 on conventional settings
Demand cpap just cracked open
Percussion rate 500
450 if primarily hypercarbic
550 if primarily hypoxic
Range 400-700
Little i:e 1:1 always
Fio2 at current need
Place on patient and adjust as needed
Pulsatile flow to chest rise
Pulsatile flow by 2
Watch chest rise for stopping point
Percussive frequency for chest wiggle
Adjust percussive rates by 25
Check peep for excessive FRC
O-cpap by 2
I-time and E-time by 0.5
I: E by 0.5
Watch T-com, spo2, cvp and NIRS as available
Obtain blood gas and Xray (expansion target 8-9 ribs)
Ventilation
To improve ventilation and lower the patients CO2
Increasing pulsatile flow to acceptable chest rise by 2
Decreasing the pulse frequency by 25
Might decrease SpO2
Increase convective rate by shortening expiratory time and keeping the inspiratory time the same
If too short on the E-time, it might cause air trapping and lead to increased CO2
Decrease O-Cpap
Might decrease SpO2
If the patient has good chest wiggle, inverse the I:E ratio by 0.5
Increase i-time and decrease e-time incrementally
Convective Rate of 20, I-time of 1.5 and E-time 1.5 for a ratio of 1:1
Convective Rate of 20, I-time of 1.8 and E-time 1.2 for a ratio of 1.5:1
Convective Rate of 20, I-time of 2 and E-time 1 for a ratio of 2:1
This could increase intrathoracic pressure and affect cardiac output by impeding venous return
Always start with the patient having enough chest rise and i-time to recruit lung volume. Without them, other adjustments will not be effective
Oxygenation
To oxygenate and increase the patients spo2
Increase fio2
Increase O- CPAP
Might increase CO2
Increase the percussion frequency
Might increase CO2
Increase pulsatile flow
Check for excessive chest rise
Might decrease CO2
Inverse the I:E ratio by 0.5 by increasing convective inspiratory time and decrease expiratory time while keeping the convective rate the same
This will increase MAP by and might drop CO2 by adding more percussive ventilation to the I-time
Convective Rate of 20, I-time of 1.5 and E-time 1.5 for a ratio of 1:1
Convective Rate of 20, I-time of 1.8 and E-time 1.2 for a ratio of 1.5:1
Convective Rate of 20, I-time of 2 and E-time 1 for a ratio of 2:1
Start Nitric
IPV TX’s on VDR
Order for IPV treatment placed with a desired frequency
Policy allows the RT to manipulate the pulse frequency between 300-600 during the treatment in a manner that results in best practice
Technique is as follows
Take note of all vitals, including if available, CVP, NIRS and TCOM
Transition patients pulse frequency to a slower rate below set rate
Lavage and hold for up to 1 minute
Suction patient and monitoring vitals
Transition pulse frequency past what is set to a faster rate (for recruitment of possible loss volume from suction maneuver
Hold for up to 1 minute
Monitor vitals
Place patient back to ordered pulse frequency and allow the patient to rest
Monitor vitals
Repeat cycle up to 3 times
Shorten time of percussive frequency if CVP, NIRS or TCOMS change dramatically
Notify physician of any adverse events
Example
Current pulse frequency currently is 500
Change to 350 and lavage and suction for up to 1 minute, monitor vitals
Change to 600 and hold for up to 1 minute, suction and monitor vitals
Change back to 500, hold and monitor until base line vitals