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HFOV - nursing management of the neonate

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Infant positioning when initially setting up for HFOV

Very important to think about how you are going to place your equipment prior to commencing High frequency Oscillation.

  • Remember the oscillator must be plugged into the red uninterrupted power supply supply (UPS) at all times
  • Place the oscillator to the side of the ponta where the red UPS and Neopuff are located. Allow enough space behind the oscillator for someone to fit behind it.
  • Make sure you can easily access the neopuff.
  • The incubator or heat table will need to be turned and placed sideways.
  • Place the oscillator tubing through the bottom of a heat table or through the top porthole of an incubator.
  • Slight elevation of the oscillation tubing is required to assist with rain out and enable good drainage.

Positioning once HFOV is established

Once it is established that the patient is tolerant of being oscillated (not all patients will tolerate HFOV, in some cases a return to conventional ventilation will be indicated), then it is possible to reposition the baby.

  • always nurse on a gel mattress
  • oscillation and prone positioning more often than not go together.

When repositioning baby:

  • use a minimum of two people, more if available
  • have one person dedicated for the head and ETT
  • have one person dedicated to moving the oscillator into postion

The images below show the positioning of oscillator and equipment around the bed space

Oscillator 1  Oscillator 2  Oscillator 3

Assessment and monitoring of an infant on HFOV

  1. Visibly assess the chest vibration and note changes. Unlike conventional mechanical ventilation (CMV), you cannot assess a rise and fall of the chest. You need to assess the amount of vibration being produced. Vibration mainly in the neck could indicate a dislodged ET tube and asymmetry vibration could indicate pneumothorax. The vibration produced depends on the amount of amplitude and lung compliance. 
    Use a visual assessment of the depth of bounce ranging from the umbilicus to the clavicle.
  2. An ABG needs to be done 10-15 minutes after going onto oscillation. In that first hour another 2-3 ABG's will probably be required as oscillation can produce significant changes in oxygenation and ventilation (CO2). After the 1st hour ABG;s should be done after any change in oscillation settings, or any clinical reason that deems an ABG to be done (e.g. falling saturations, increased saturations).
    Otherwise 6 hourly if stable and minimal changes occurring with the oscillator settings.Frequent blood gas monitoring is required at first to assess effectiveness of HFOV.
  3. Ensure CXR taken within ½ hour after commencement of oscillation, to assess the degree of lung distension, to ensure adequate alveolar expansion and to check that hyperinflation has not occurred. This will determine MAP setting.
    NOTE: X-rays may be performed through mattress.
  4. Amplitude, Hz, FiO2 and MAP settings must be clearly documented by NS-ANP/Medical staff on the level 3 chart.
  5. Monitoring of infant's heart rate may be problematic via ECG electrodes. Heart rate can be monitored as a 'pulse' through the UAC .
    Evaluation for heart murmurs may require a temporary pause in HFOV therapy.
  6. Assess infant's neurological and behavioural state on HFOV. Analgesia and sedation may be required for comfort and avoidance of ET tube dislodgment.
  7. Blood Pressure. Be prepared for a potential blood pressure drop; this is due to the increased intra-thoracic pressure that oscillation can cause, resulting in decreased venous return. Have volume and / or an inotrope (usually dopamine) ready.
  8. Auscultation:
    Listening to breath sounds in infants ventilated on HFOV may be helpful, as the sounds (friction sounds) become reduced in the affected side when the endotracheal tube is low and ventilates only 1 lung or when a pneumothorax is present. These changes may occur before the infant becomes symptomatic. Thus auscultation should be performed at the time of routine assessment or if there is clinical deterioration.

Nursing management of an infant on HFOV

Positioning

  • The brakes on the oscillator and incubator / heat table must always be on.
  • Position the oscillator and incubator/heat table diagonally across the bed space.
  • Careful positioning of the oscillator is required to avoid pulling on ET tube. Know and check hourly your ETT landmark.
  • Ensure the incubator or heat table is slightly higher than the oscillator to promote circuit drainage of rainout from the humidification.
  • Position the infant's body in alignment with the oscillator so that only the head is being moved when it is time for a position change.

Repositioning

  • Should be individually assessed on condition of skin integrity and infant physiological status. You will need a minimum of two people.
  • Gel mattress must always be used.
  • Do not disconnect tubing during repositioning.

Disconnection

  • Disconnection is discouraged as it can cause alveolar collapse and loss of lung volume.
  • Use of Neopuff is discouraged unless mechanical failure or severe deterioration of infant's condition.

Suction (see Suction protocol for full procedure)

  • In-line suction must be used.
  • Press Stop button briefly on SensorMedics while briefly inserting and withdrawing catheter. PAW is maintained throughout.
    Rationale for pausing - The oscillator causes a pressure pulse in the airways. When suctioning if the sensormedics isn't turned off the secretions get pushed back down because of this pulse pressure. So you are having ineffective clearance of secretions. There is also the potential of air trapping with active piston movement.

Weighing

  • Infants should not be weighed on HFOV routinely.
  • Only weigh an infant if specifically ordered and discussed on ward round.
  • Always use a warm weigh scale.

X-ray SensorMedics only

  • Turn oscillations off at start/stop knob briefly while X-ray is taken
  • Remember if MAP is lost, the reset button will need to be held down to restore MAP and then you can press start again.

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Document Control

  • Date last published: 23 March 2011
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years