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Clinical Simulation The following simulation was modified from simulations developed by Dr. Alan Spitzer from Thomas Jefferson University Hospital, Philadelphia, PA. The baby is a 1200 gram premature infant, born at 31 weeks gestation. Within thirty minutes of birth, the child is noted to be cyanotic, grunting, and retracting. You suspect RDS and get an xray that confirms your suspicion. Pulse oximetry reveals that the oxygen saturation is only 82%. The child is intubated and put on a conventional ventilator. CV Settings: Rate PIP PEEP FiO2 I.T. 40 25 5 0.60 0.5 ABG @ 20 minutes: pH PO2 PCO2 7.26 51 52 What do you do? At 14 hours of life the nurse reports that the child has suddenly become very cyanotic again. Breath sounds are decreased on the right. You transilluminate and discover a pneumothorax. After the chest tube is placed you increase ventilator support. CV Settings: Rate PIP PEEP FiO2 I.T. 60 32 5 1.0 0.3 ABG @ 20 minutes: pH PO2 PCO2 7.32 62 44   The baby's condition continues to worsen over the next hour. Rather than going up on conventional support, you decide to switch the patient to the Life Pulse™ High Frequency Jet Ventilator ("Jet"). Why switch to the Jet at this time? What are your initial settings? Since the patient has an active airleak, you elect to start the Jet on a slightly lower peak pressure than the original conventional PIP. CV Settings: Rate PIP PEEP FiO2 I.T. 0 28 6 1.0 0.3 HFV Settings: Rate PIP I.T. 420 29 0.02 ABG @ 20 minutes: pH PO2 PCO2 7.42 55 36   What information do you need before making any changes? What changes do you make? The mean airway pressure (MAP) dropped from 15.2 to 12.7 when you switched from CMV to HFJV. You want to increase MAP in the hope it will improve oxygenation. What are your options for increasing MAP? Is there a preferred approach for this patient? You decide on a conservative approach to address two different issues that affect oxygenation. You increase the PEEP by one to increase MAP directly. You also add in two CMV breaths to recruit alveoli that may have collapsed during the transition from CMV to HFJV. CV Settings: Rate PIP PEEP FiO2 I.T. MAP 2 28 7 1.0 0.3 14.1   HFV Settings: Rate PIP I.T.   420 29 0.02     ABG @ 20 minutes: pH PO2 PCO2   7.40 67 40     How do you respond? The chest x-ray looks significantly better six hours later and the chest tube has stopped bubbling. The O2 saturation has steadily improved, as well; the oximeter is now reading 100% for the first time since the patient went on the Jet. You decide to get an ABG to see how well it is correlating. CV Settings: Rate PIP PEEP FiO2 I.T. MAP 2 28 7 .85 0.3 14.1   HFV Settings: Rate PIP I.T.   420 29 0.02     ABG @ 20 minutes: pH PO2 PCO2   7.51 132 28     How do you account for the patient's improvement? How would you respond to this ABG? Since RDS is still present you elect to leave the PEEP alone for now and continue weaning FiO2 per the oximeter. To increase CO2 you decide to decrease the PIP to 27 on both ventilators. CV Settings: Rate PIP PEEP FiO2 I.T. MAP 2 27 7 .72 0.3 13.9   HFV Settings: Rate PIP I.T.   420 27 0.02     ABG @ 20 minutes: pH PO2 PCO2   7.42 90 36     Where do you go from here?   The baby continues to do well over the next three days. CV Settings: Rate PIP PEEP FiO2 I.T. MAP 5 16 4 .47 0.3 8.7   HFV Settings: Rate PIP I.T.   420 16 0.02     ABG @ 20 minutes: pH PO2 PCO2   7.27 77 53     How do you respond? At this point the patient is ready to wean off the Jet. Rather than responding to the ABG's by increasing Jet support you would increase conventional support. The CMV rate could be raised to ten breathes per minute. This would raise MAP to support oxygenation and would also increase minute ventilation to decrease CO2. Once it is obvious that the CMV is doing most of the work of breathing you can put the Jet in Standby and trial the patient on CMV. The Jet should be restarted, if the CMV rate and PIP have to be increased too dramatically. The weaning process is different for every patient, so listen to your patient and be flexible.

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