CLINICAL GUIDELINES ID TAG

High Frequency Oscillatory Ventilation

Title: (HFOV) of Neonates using SLE5000
Ventilator

Author: Dr David Grier

Speciality / Division: Neonatology
Directorate: CYP
Date Uploaded: 31st May 2016

Review Date 12th November 2021

Clinical Guideline ID CG0093[2]

 Children & Young People’s Directorate
Paediatric-Neonatal Guidelines Checklist & Version Control Sheet

1 Name of Guideline / Policy/ High Frequency Oscillatory Ventilation (HFOV) of

Neonates using SLE5000 Ventilator
Procedure
2 Purpose of Procedure/ Guidelines/ For Use of High Frequency Oscillatory Ventilation
(HFOV) of Neonates using SLE5000 Ventilator
Protocol:
3 Replaces: High Frequency Ventilation of Neonates

4 Professionals consulted during Dr David Grier, Consultant Paediatrician

development

5 Applicable to which staff: Neonatology

6 Name & Title of Author: Dr David Grier, Consultant Paediatrician

7 Proposals for dissemination: Clinical Guidelines Web Portal SHSCT

8 Proposals for implementation: Currently being Implemented

9 Training Implications: Regular Updates of Ventilation in CAH Neonatal Unit

10 Date Procedure/Guideline/ Protocol

22/02/2016
submitted to Procedures
Committee:
11 Outcome: Approved Dr Khan, AMD, Chair- Clinical Governance
Steering Committee
Approved/Minor
amendments
Not approved
Deferred
12 Date of CYP SMT approval 22/04/2016
Comments:
13 Date of approval by Trust SMT (if N/A
required):
14 Date for further review (3 year Reviewed 12/11/2019
default)
15 Date added to repository:
Note: Guideline author to complete parts 1-10
High Frequency Oscillatory Ventilation using SLE5000 Ventilator

High Frequency Oscillatory Ventilation (HFOV) is a form of mechanical ventilation in which small tidal
volumes, at or just less than the anatomical dead space and therefore can be seen as lung-
protective, are delivered at very rapid rates, typically 10Hz – 15Hz (600-1200 BPM) The pressure
oscillates around a set mean airway pressure. The magnitude of the oscillation is the amplitude
(Delta P).

Potential advantages include lower airway pressure; adequate & independent management of CO2
& O2 with low tidal volumes and preservation of normal lung architecture even with high airway
pressure.

Indications: severe RDS, persistent pulmonary hypertension, persistent air leaks, congenital
diaphragmatic hernia or when the response to conventional ventilation is inadequate. Consider
HFOV if peak pressures on conventional are 25cm H2O or higher.

Before commencing HFOV ensure the following:

1. Continuous SpO2 monitoring
2. Chest X-Ray to confirm endotracheal tube position, to assess degree of inflation with current
mean airway pressure and confirm homogeneity of the lung disease (theoretically HFOV works best
in homogenous lung disease).
3. Arterial access, if possible, to allow:
a. Regular monitoring of blood gases
b. Continuous blood pressure recording
The SLE5000 has four controls. In order from left to right:

1. HFOV Rate (Hz). Tidal volume increases as frequency falls, therefore, increasing the frequency
increases the PaCO2 and decreasing the frequency decreases the PaCO2: this is the converse to
conventional mechanical ventilation. In practice HFOV is adjusted infrequently; CO2 is normally
controlled using the delta P.

2. Mean [airway pressure]. The lungs are inflated and kept open by this constant distending
pressure. As lung compliance changes the amount of distending pressure will need to be adjusted.
Oxygenation varies with mean airway pressure. Frequent chest X-rays are necessary to ensure
optimal lung expansion – aiming for 8-9 posterior ribs.

3. Delta P. Often called amplitude. An increase in delta P will blow off more CO2 thus lowering the
PaCO2. With delta P below 18 the ability of the SLE 5000 to oscillate is affected.

4. FiO2
CO2 elimination is affected by Delta P (& HFOV rate).

Oxygenation is affected by Mean & FiO2.

Starting HFOV

1. While in SIMV or other mode of ventilation press “Mode Select” on the top left hand corner of the
screen.
2. Then press “HFO only”.
The four controls will appear at the bottom of the screen. These can be set while the ventilator
continues to ventilate on the previous settings and will not take effect until “Confirm” is pressed.
3. Set HFOV Rate – start at 10 Hz for term infant and 12 to 15 Hz for preterm infant
4. Set Mean – start at 2 cm H2O above the current mean airway pressure (on conventional
mechanical ventilation)
5. Delta P cannot be set at this point
6. Set FiO2
7. Press “Confirm” to initiate HFOV
8. increase Delta P until the infant‟s upper thighs oscillate
9. An Arterial Blood Gas should be taken 15 minutes after starting HFOV as PaCO2 can change
quickly.
10. A chest X-ray should be done within 30 minutes of starting HFOV to assess lung expansion; the
mean should be adjusted so that 8-9 ribs may be seen posteriorly.

Alveolar/Airspace Recruitment

Any break in the circuit, for example with suction, will lead to reduced alveolar expansion. In
addition over time derecruitment of alveoli gradually occurs. Recruitment manoeuvres should be
performed with every circuit break or suction and every 4 hours if not done for other reasons.
1. Increase mean airway pressure 5 cm H2O above the set pressure for 30 seconds
2. Return mean airway pressure to the set pressure

Monitoring

It is useful to have continuous transcutaneous CO2/PO2 monitoring when switching to HFOV as

HVOF can be associated with rapid reductions or changes in ventilation – „TINA‟ (transcutaneous
O2/CO2 recordings, real-time) can guide adjustments.

It is useful to note the tidal volume on oscillation (Vte) and DCO2 values when stable during
oscillation (available on the right side of the ventilator screen. Beware sudden reductions in Vte or
DCO2 levels – these and/or desaturations will often be the first sign of retained secretions (partial
tube blockage) and should prompt suctioning to clear secretions‟. A typical Vte on oscillation is 1-
2ml/kg.

Over-ventilation on oscillation may be heralded by high Vte levels (and relatively higher DCO2) – be
prepared to check gases or transcutaneous trends regularly.
Common pitfalls

1. Desaturation (when lung compliance is expected to be improving.)

 This may be due to lung over distension

 Always consider decreasing mean airway pressure rather than increasing it

2. Disconnection from HFOV for suctioning.

 Leads to atelectasis; use closed circuit suction.

3. Falling blood pressure.

 This may be a sign of over distension. Check a chest X-ray. Consider reducing mean airway
pressure before volume expansion or starting inotropes.
 Occasionally early desaturation after switching to HFOV may imply hypovolaemia- give a
fluid bolus if the clinical situation dictates to maintain optimal venous return.

Weaning from HFOV

Gradually wean mean airway pressure and delta P according to blood gases. There are then two
options:

A. Change to SIMV when below a value of mean airway pressure determined by the consultant. Then
wean on conventional ventilation.

B. Or, wean to MAP ≈ 8 cm H20 and extubate directly to CPAP

References: this guideline has been adapted from the guideline currently in use in the Neonatal Unit
in the Royal Jubilee Maternity Service