High Frequency Oscillatory Ventilation

[Airlife91]

We have an EP doc that does a fair amount of Afib ablations - pulmonary vein isolation ablation procedures. For these cases he likes the patient to be placed on a high frequency oscillatory ventilator to reduce respiratory motion. He states this increases the precision of his ablation and increases success rates. I have done EP at a few other places and have never encountered this technique before. Other facilities have just asked us to decrease the TV and increase RR to accomplish something similar.

We have had no problem accommodating this for our anesthetic, but we have always had an RT come down to run the oscillator. This has been a challenge as our hospital is short on RTs. The other EP docs are now wanting to use the oscillator, but RT can’t accommodate it, so they’re asking us to run the oscillator. Thoughts on this? None of the anesthesiologists in my group have much experience running the oscillator. We‘ve also had challenges sourcing the circuits for the oscillator….mainly because its really old.

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[BLADEMDA]

Figure 64.6 Hunsaker tube. Note green basket and metal stylet.

 

[BLADEMDA]

 

[Urzuz]

We went through the same thing in our department around a year ago. I was skeptical at first but the EP department bought it so figured we would go along with it.

Monsoon III Jet Ventilator | Medical Equipment Sales and Service | Susquehanna Micro Inc.

Susquehanna Micro Inc. a leader in the sales of Acutronic's Monsoon III Jet Ventilator. Contact us today to request a quote for your hospital or medical practice. We also offer quality service and repair for the Acutronic Monsoon III Jet Ventilator.

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This is the jet ventilator we got. It is actually quite sophisticated versus the hand jet ventilators that we were trained on in residency.

For what it’s worth, every EP doc we have swears by it now and says it’s game changing for them. For our high volume / “best” EP doc, it cut his ablation time down significantly. He is extremely thorough and used to take up to 5-6 hours for AFibs in the past — this is down to 2-3 now. We sometimes will now do 3-4 AFibs in a day, and per his testimony, his reduction in time is all due to the contact of the ablation catheters with the heart being significantly improved with the reduced respiratory motion.

 

[BLADEMDA]

Clinical Skills: High-frequency oscillatory ventilation (HFOV) - Osmosis Video Library

Clinical Skills: High-frequency oscillatory ventilation (HFOV) Videos, Flashcards, High Yield Notes, & Practice Questions. Learn and reinforce your understanding of Clinical Skills: High-frequency oscillatory ventilation (HFOV).

www.osmosis.org

 

[BLADEMDA]

The OP needs to meet with administration and buy 2-3 of these ventilators. The device rep. will show up an "in-service" you on the ventilator.
No equipment means no HFJV.

https://anesth.utmb.edu/residents/Documents/Monsoon%20Manual.pdf

 

[BLADEMDA]

High Frequency Jet Ventilation During Ablation of Supraventricular and Ventricular Arrhythmias: Efficacy, Patient Tolerance and Safety

High Frequency Jet Ventilation During Ablation of Supraventricular and Ventricular Arrhythmias: Efficacy, Patient Tolerance and Safety

www.innovationsincrm.com

 

[BLADEMDA]

https://www.sciencedirect.com/science/article/pii/S2405500X18307254

Good article. If I was going to start HFJV in the cath lab I would demand the equipment including the ventilator, tubes, Infusion pumps, pressors and BIS.

 

[Urzuz]

Jet Ventilation isn't the same as HFOV. They both may work for A. Fib ablations but they aren't the same type of ventilation.

You are correct, it isn’t the same, and I can see how my post made it sound like I thought they were.

Obviously the EP docs don’t care about the physics of how you’re ventilating the patient - they just want the heart to remain stable.

 

[GassYous]

We went through the same thing in our department around a year ago. I was skeptical at first but the EP department bought it so figured we would go along with it.

Monsoon III Jet Ventilator | Medical Equipment Sales and Service | Susquehanna Micro Inc.

Susquehanna Micro Inc. a leader in the sales of Acutronic's Monsoon III Jet Ventilator. Contact us today to request a quote for your hospital or medical practice. We also offer quality service and repair for the Acutronic Monsoon III Jet Ventilator.

www.susquemicro.com

This is the jet ventilator we got. It is actually quite sophisticated versus the hand jet ventilators that we were trained on in residency.

For what it’s worth, every EP doc we have swears by it now and says it’s game changing for them. For our high volume / “best” EP doc, it cut his ablation time down significantly. He is extremely thorough and used to take up to 5-6 hours for AFibs in the past — this is down to 2-3 now. We sometimes will now do 3-4 AFibs in a day, and per his testimony, his reduction in time is all due to the contact of the ablation catheters with the heart being significantly improved with the reduced respiratory motion.

Well I don't wanna be doing 3-4 afibs in a day so...

 

[Beeftenderloin]

Our EP docs just request us to drop the tidal volumes during that part of the procedure. Frequency doesn’t effect it at all, just volume. I just drop my Vt to something that starts with a 3 or 4 and go up on the rate. I never get complaints at volumes that low.

 

[Airlife91]

We went through the same thing in our department around a year ago. I was skeptical at first but the EP department bought it so figured we would go along with it.

Monsoon III Jet Ventilator | Medical Equipment Sales and Service | Susquehanna Micro Inc.

Susquehanna Micro Inc. a leader in the sales of Acutronic's Monsoon III Jet Ventilator. Contact us today to request a quote for your hospital or medical practice. We also offer quality service and repair for the Acutronic Monsoon III Jet Ventilator.

www.susquemicro.com

This is the jet ventilator we got. It is actually quite sophisticated versus the hand jet ventilators that we were trained on in residency.

For what it’s worth, every EP doc we have swears by it now and says it’s game changing for them. For our high volume / “best” EP doc, it cut his ablation time down significantly. He is extremely thorough and used to take up to 5-6 hours for AFibs in the past — this is down to 2-3 now. We sometimes will now do 3-4 AFibs in a day, and per his testimony, his reduction in time is all due to the contact of the ablation catheters with the heart being significantly improved with the reduced respiratory motion.

Are you running the ventilator or is an RT?
The oscillating vent we have is the same as the device photo blade posted. We already do the procedures with HF oscillatory ventilation using that machine, but we have an RT to run the machine. We do it probably twice a month. The problem is that now the other EP docs want to do it too and the resp dept doesn’t want to provide an RT to run that machine more than 1-2 days/mo, so they want us to run it instead. Nobody in my group has any experience running an oscillator except a couple peds folks who used them in the PICU in training. I’m sure it’s not all that complicated, but it does seem like we could just increase the RR and decrease the TV like others have suggested.

 

[Urzuz]

Are you running the ventilator or is an RT?
The oscillating vent we have is the same as the device photo blade posted. We already do the procedures with HF oscillatory ventilation using that machine, but we have an RT to run the machine. We do it probably twice a month. The problem is that now the other EP docs want to do it too and the resp dept doesn’t want to provide an RT to run that machine more than 1-2 days/mo, so they want us to run it instead. Nobody in my group has any experience running an oscillator except a couple peds folks who used them in the PICU in training. I’m sure it’s not all that complicated, but it does seem like we could just increase the RR and decrease the TV like others have suggested.

We run the jet ventilator ourselves. It has some weird quirks but it’s very easy once you mess around with it a few times and understand how it works and how the different parameters affect your physiologic values.

Usually after intubating the patient and starting the jet ventilator, most people will check POC ABGs a few times in the first hour to make sure the PaCO2 is landing at an appropriate level, and manipulating the parameters of the vent to achieve their desired values. After that, you’re pretty much on cruise control. It’s amazing how good the device is at keeping patients well oxygenated / ventilated.

The anesthesia machine is still hooked up to the patient so if for whatever reason you ever felt uncomfortable or the device was going haywire, you could always flick the anesthesia machine ventilator on and turn the jet ventilator off.

The company has a rep that will give your department an inservice on the device.

 

[kb1900]

first time I saw someone needle decompress a tension ptx was in a monsoon jet. can see how it can be hard to assess chest wall egress in some cases

 

[pocafx]

In residency we used the monsoon jet vent. Worked most of the time, if had problems would just do small TV and increased RR.

 

[Urzuz]

first time I saw someone needle decompress a tension ptx was in a monsoon jet. can see how it can be hard to assess chest wall egress in some cases

I’m surprised to hear this because there is a pressure manometer that constantly measures pressure and will stop the ventilator from delivering the jet once the pressure goes higher than whatever your pressure limit is.

I can’t help but wonder if the equipment was faulty, it was an older model that maybe didn’t have the same functionality that the new one does, or it was user error (the anesthesiologist cranked the pressure limit way up not understanding what he/she was doing, combined with manipulating other settings which didn’t allow for egress etc). For what it’s worth, I never saw an instance of breath stacking for all the times I used it, but I also followed their “recommended settings” very closely save for small changes in the driving pressure and the inspiratory time.

 

[cchoukal]

Are we conflating OSCILLATORY with JET ventilation? The HFOV kind of makes sense for EP, but I’m having a hard time putting that together with all these mentions of jets and special tubes.

 

[Urzuz]

Are we conflating OSCILLATORY with JET ventilation? The HFOV kind of makes sense for EP, but I’m having a hard time putting that together with all these mentions of jets and special tubes.

No, we’re not. The use of HFJV improving catheter stability in EP has been a somewhat hot topic for them in their literature and at their meetings in the past several years. I would guess more and more of them will start asking for it if/when they hear from their colleagues about it. As I said, I was skeptical it would make a significant difference over the normal tidal volume decreases we used to do, but our EP docs swear by it now. Maybe it’s their coping mechanism for blowing their department’s funds on a new piece of anesthesia equipment when they could have invested in a new way to cool the esophagus…🤔

 

[DoctwoB]

As a urologist can I request this for ureteoscopy? Y'all love making the kidney bounce around like a pinball.

 

[Mehd School]

As a urologist can I request this for ureteoscopy? Y'all love making the kidney bounce around like a pinball.

Like I tell many other surgeons, breathing is an unfortunate side effect of life.

 

[GassYous]

As a urologist can I request this for ureteoscopy? Y'all love making the kidney bounce around like a pinball.

I've noticed that it is the ****ty surgeons that complain the most

 

[nimbus]

As a urologist can I request this for ureteoscopy? Y'all love making the kidney bounce around like a pinball.

CPB/circ arrest for everyone! Bloodless/motionless field like operating on a cadaver

 

[Maz777]

I've noticed that it is the ****ty surgeons that complain the most

Exactly. Strong correlation between the whiniest surgeons and lack of surgical skill.

 

[DoctwoB]

It's funny how bad anesthesiologists seem to work with a lot of bad surgeons. 😋

 

[GassYous]

It's funny how bad anesthesiologists seem to work with a lot of bad surgeons. 😋

It's called residency

 

[WholeLottaGame7]

Just have them do them all on VA-ECMO. Just think how fast they'll be with NO diaphragmatic movement!