Journal of Neonatal Nursing (2012) 18, 112e120

www.elsevier.com/jneo

EDUCATION ISSUES

High frequency ventilation: A reflective casestudy

Hilarious De Jesus a,*, Julia Petty b

aNeonatal Unit, The Royal London Hospital, Barts Health NHS Trust, London, UKb School of Health Sciences, City University, London, UK

Available online 12 June 2012

Abstract Reflection is widely used in nurse education for both the learner to

demonstrate learning from one’s nursing actions and for the educator to assesshow such learning has been applied to clinical practice. There is much to belearnt from any clinical situation but perhaps the most effective way to extractissues from practice is to reflect on case examples. This paper outlines a reflec-tive care study of a specific baby in the neonatal intensive care unit (NICU)illustrating how focusing on only one case within a short time frame cancapture issues for discussion and analysis. The focus of this paper is on thelearning points relating to a baby receiving HFOV specifically, during onenursing shift.ª 2012 Neonatal Nurses Association. Published by Elsevier Ltd. All rightsreserved.

Introduction

Reflective practice has been recognised asa viable tool to promote critical thinking in nursingpractice (O’Connor, 2008). Having reflectiveability allows the nurse to structure thought

* Corresponding author. The Royal London Hospital, BartsHealth NHS Trust, Whitechapel, London.

E-mail address: Hilarious.DeJesus@bartshealth.nhs.uk(H. De Jesus).

1355-1841/$ - see front matter ª 2012 Neonatal Nurses Associationdoi:10.1016/j.jnn.2012.05.010

processes directed towards critically analysinga situation with improvement in skill or change inbehaviour as its outcome (Johns, 1995; Mannet al., 2009). Aside from the intangible nature ofreflection, significant literature supports the useof reflective practice in healthcare to bridge theinfamous “theory-practice gap” (O’Callaghan,2005; Duffy, 2008; Cricco-Lizza, 2010).

In this reflection, iterative and vertical dimen-sions of reflection shall be demonstrated (McBrien,2007). Iterative dimension is reflection that is trig-gered by an experience (Mann et al., 2009) in this

. Published by Elsevier Ltd. All rights reserved.

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case relating to the care of a very sick baby withcongenital diaphragmatic hernia (CDH) requiringhigh frequency oscillatory ventilation (HFOV). Thevertical dimension refers to the varying degree ofthe reflector to dissect the whole experience andcomeupwithnew insights leading to transformationin practice (Mann et al., 2009). The reflection isfrom the experience of a ‘novice’ nurse within theneonatal intensive care environment. This refers toBenners levels of experience within nursing fromnovice to expert (Benner, 1984).

Description; case study

A 38 week old male (Baby H) was born on a leveltwo neonatal unit with declining Apgar scores (i.e.10, 8, 4); grunting and respiratory distress with anincreasing oxygen requirement was observed at30 min of life and radiography revealed the pres-ence of gut in the left lung field. General assess-ment showed that the baby was very pale, feltperipherally cold and floppy. The chest was movingsymmetrically but with diminished air entry on theleft lung field. A four millimetre endotracheal tube(ETT) was secured at 8 centimetres at the lips.Vital signs were stable with current ventilationsettings although the mean blood pressure drop-ped intermittently to <35 mmHg.

The baby was then immediately referred toa level 3 neonatal surgical unit for further inves-tigation following a diagnosis of CDH.

During admission, the baby was on conventionalventilation of Synchronised Intermittent Manda-tory Ventilation (SIMV) but was changed to HighFrequency Oscillation Ventilation (HFOV) followingadmission to the receiving unit. The baby had anechocardiography which revealed increasingpulmonary pressure.

From this point on, procedures included: inser-tion of umbilical arterial and vein catheters (UACand UVC), initiation of pancuronium to musclerelax the baby, along with morphine for sedationand analgesia, administration of one bolus of 10millilitres per kilogram of 0.9% sodium chloridesolution to boost the systemic blood pressure fol-lowed by the initiation of dopamine at 20 mcg/kg/min to aim for a mean blood pressure of>40 mmHg. Inhaled nitric oxide (iNO) was alsoinitiated at 20 parts per million (ppm). Abdominaland chest radiographs were taken. The parentswere spoken to so that they were fully informedabout the condition and interventions at all stagesof the baby’s transfer and admission.

Personal reflection: an evaluation

At the start of the shift, I (Hilarious De Jesus) wasallocated to look after Baby H. Initially, this mademe feel apprehensive as I had never nursed a babyreceiving HFOV and iNO before. Braithwaite (2008)highlighted that due to high levels of specialistskills necessary, neonatal intensive care unit(NICU) nurses can experience varying degrees ofstress. Therefore a sense of uncertainty is indeednormal for the novice nurse undertaking a newarea of practice. It was imperative however that Igained this experience to learn for future practice.

However, of great value were the support andconfidence from my senior colleagues. The transi-tional shock theory (Duchscher, 2008) explains thatdisproportionate expectations versus experienceamong inexperienced nurses can lead to “transitionshock” but can be mitigated by good support fromsenior colleagues. The senior nurse on duty reas-sured me that help would always be availableshould I need it and that supervision would be givento me throughout the whole shift. Furthermore,provision of adequate support from seniorcolleagues is essential when “breaking in” novicenurses on novel roles (Hoffman et al., 2009). One ofthe key roles by novice nurses is to disambiguate thetheory-practice gap, of which senior support isindispensable (Benner, 1984; Messmer et al., 2004).

Literature shows that novice nurses view situa-tions in a linear manner that tend to providea parallel existence of nursing knowledge andactual context of the clinical situation (Gillespieand Paterson, 2009). The whole novelty of theexperience can prevent nurses from recognisingthe clinical context and its relation to existingnursing knowledge. However, in this case these

114 H. De Jesus, J. Petty

feelings started fading once I started nursing thebaby.

Also central to my care at this level as ‘novice’is the mandate to provide safe and evidence-based care for babies and their families. The codeof practice mandates that care provided should beof the highest quality and risks should be managedaccordingly (Nursing and Midwifery Council,2008). In this case, I felt that embarking on“untested waters” of nursing the baby on HFOV isassociated with potential risks. Ethically, I knewthat I had to act on my patient’s and family’s bestinterest in balance with my own training needs.This does pose a potential challenge to a novicenurse. However, research shows that awareness ofan ethically-aware unit culture decreases moraldistress among practitioners (Ulrich et al., 2010).

Turning now to the clinical analysis, the papercovers the specific learning points in relationto HFOV.

Analysis

CDH

To understand the underlying pathophysiology inthis baby’s case, it is necessary to consider that ofCDH (see Fig. 1). To add, literature shows thatpathogenesis of CDH involves two underlyingpathologies: fixed (pulmonary and vascular hypo-plasia) and reversible (pulmonary vascular reac-tivity) (Hedrick, 2010). Historically, inducedrespiratory alkalosis was used to reduce the effectsof the latter with a view of preventing deteriorationdue to persistent pulmonary hypertension (PPHN)

Figure 1 Learning points. Congenital Diaphragmatic Herni2005; Dewhurst et al., 2007; Hernandez-Diaz et al., 2007)

(Loganet al., 2007); hypercapnia combinedwith theexisting pulmonary and vascular hypoplasia in CDHmay lead to PPHN (Spillers, 2010).

Baby H showed a rising CO2 along with a diag-nosis of PPHN. Therefore, it made sense to addressthe developing hypercapnia and hypoxaemiaimmediately through the shift from a conventionalventilation mode to a different type of strategy. Inthis case, HFOV was immediately utilised after thebabie’s admission.

HFOV

HFOV is known as a non-conventional mode ofmechanical ventilation and a summary of thisstrategy can be seen in Fig. 2.

The shift to HFOV in this case was necessary fortwo main reasons: 1. SIMV setting with high pres-sures may induce ventilator induced lung injury(VILI), 2. HFOV provides a lower tidal volume buthigher MAP than conventional ventilation andpotentially provides better lung recruitment.Firstly, Baby H was initially on SIMV with a rate of45 breathes per minute and a pressure of 25/6cmH2O. In post-mortem studies of babies who diedwith CDH ventilated with high mean airway pres-sure (MAP), histological results revealed higherinflammatory markers indicative of tissue injury(Hedrick, 2010; Keijzer and Puri, 2010). Further-more, conventional ventilation has been associ-ated with fluctuating pressures that can lead toalveolar collapse that eventually results in ate-lectrauma (Hedrick, 2010).

In this case, the ventilation for the baby on HFOVmaintained a MAP of 11e13 cmH2O. Progressiveradiograph results showed no acute lung changes

a (CDH) (Doherty and MacKinnon, 2006; Moya and Lally,

Figure 2 Learning points. High Frequency Oscillatory Ventilation (HFOV) (SLE, 2009; Bellettato et al., 2011;Thome and Carlo, 2003; Thome et al., 2005; Henderson-Smart et al., 2007; Cools et al., 2009; Marlow et al., 2006)(Fig. 3).

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indicative of VILI. Secondly, while on SIMV, the tidalvolume ranged between 24 ml to 30 ml. Chestradiograph also revealed left pulmonary hypoplasia.A normal tidal volume of a newborn baby is around4e6 mks/kg (Cheema et al., 2007; Singh et al.,2007). In this case, tidal volumes of >24 mls wouldmean exceeding the optimum volume that maypredispose to volutrauma. Evidence shows thatHFOV has been associated with reduced VILI due toits ability to provide an effective end expiratorypressure without the associated volutrauma andbarotrauma (Ng et al., 2008; Paulista and deMesquita, 2009; Kuluz et al., 2010).

In theory, HFOV has the intrinsic capability ofmaintaining expiratory pressures above the zone ofalveolar collapse due to the small amplitude of thetidal volumes compared to conventional ventilationthus leading to better lung recruitment (Paulistaand de Mesquita, 2009).

Six hours after the initiation of the HFOV in BabyH, radiograph results showed better lung expan-sion especially on the left hypoplastic side of thelungs. Thirdly, the baby had rising pulmonarypressures revealed by the echocardiogram.

Figure 3 Comparative waveforms for conventional verses HFOV modes. a: Waveforms for conventional ventilation eContinuous Mandatory Ventilation (CMV). b: Waveforms for High Frequency Oscillatory Ventilation (HFOV). Imagesource: http://www.sle.co.uk/_assets/documents/brochures/SLE5000.pdf Permission granted.

116 H. De Jesus, J. Petty

Inhaled nitric oxide

Some babies with severe pulmonary dysfunction donot respond to either conventional ventilation orHFOV alone and require an additional adjunctsuch as iNO (See Fig. 4). This was the case withBaby H. Inhaled NO produces localised vasodila-tation in the pulmonary circulation without thesystemic effects at optimal doses of 1e20 ppm(Dewhurst et al., 2007). iNO can be used inconjunction with conventional ventilators or highfrequency ventilators.

Airway management in HFOV

Having analysed the ventilation strategy employedin this case, it was then appropriate to shift thefocus to more practical bedside nursing care.Firstly, suctioning the endotracheal tube in a babyon HFOV was another new experience. In conven-tional ventilation, my current unit practiceinvolves open suctioning. For this baby, I used anopen suction method due to the copious secretionsresulting from neuromuscular blockade but even-tually moved to using closed suction.

There has been contradicting evidence on theadvantages of closed versus open suction. In vitrostudies suggest that there is no significant differ-ence in terms of pulmonary dynamics between thetwo suction modes (Jongerden et al., 2007; Kiralyet al., 2009) whereas other studies, althoughlimited, suggest that close suctioning may offersome advantages such as protection from de-recruitment (Hoellering et al., 2008; Tingayet al., 2010). Maintaining recruitment is of vitalimportance to sustain the desired MAP. In theabsence of a closed suctioning system, re-recruitment manoeuvres can be applied such asan increase in MAP by 1e2 cmH2O with a slighttemporary increase in delivered oxygen both ofwhich should be decreased after a few minuteswhen the babys’ vital signs return to normal

Figure 4 Learning points. Inhaled Nitric Oxide (iNO) (Dewhurst et al., 2007).

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values. This may be indicated by pulse oximetrymonitoring or by transcutaneous probe showingthe return of pCO and pO2 levels back to targetrange. In addition, suctioning frequency can beguided by visual examination of the endotrachealtube and pulse oximetry or transcutaneous probereadings. Evidence-based guidelines support theuse of suctioning based on need rather than ona routine basis, one of which is visual inspection ofET for secretions (Gardner and Shirland, 2009).Auscultation of the chest when HFOV is switchedoff but not disconnected can also be undertaken.This prevents a sharp drop in MAP.

In addition, literature advocates that suctioningduring HFOV should be done as infrequently aspossible to optimise ventilation thus, using visualinspection and monitoring are crucial. All in all,this situation shows that it would have been pref-erable to attach a closed suction system right atthe start. However, as there were constraints onthe resources at that time, I utilised the next bestsolution to the problem.

Once I had seen that the blood gases improvedusing the “impromptu” closed method, I shiftedfrom the open system. Guided with this newknowledge, it would be logical to practice closedsuction as much as possible in the future. I wouldadvocate that closed suction systems be madeavailable especially in very sick babies as well asthe availability of clear, recent and evidencebased guidelines to support practice.

Secondly, I made sure that humidification andtemperature levels of the gas administeredremained within the optimal temperature of 37 �C.

HFOV requires adequate humidification as itfacilitates air movement and promotes normalaerodynamics inside the lungs and is essential inminimising insensible water loss (Fassassi et al.,2007; Duval et al., 2009).

Temperature and humidity control are essentialin mechanical ventilation, more so in this case

where the frequency meant that 600 respirationsper minute were being delivered. Also necessarywhen nursing babies on HFOV is constant vigilanceon the integrity of the tube.

Monitoring and assessment of the babyon HFOV

The above section raises the importance ofassessment in the care of the oscillated baby suchas Baby H. The use of assessment tools augmentbedside decision making; For example, the use ofa transcutaneous probe on CDH patients especiallyduring the acute phase of the disease, where PPHNis imminent is a potentially viable tool to providereal-time information and intervene for optimumventilation (Tobias, 2009). Establishing goodcorrelations between the trancutaneous readingsand arterial blood gases may be invaluable inproviding information on ventilation and perfusionstatus (Bhat and Abhishek, 2008; Tobias, 2009).Transcutaneous monitors may not be used oravailable however and pulse oximetry may bemore commonplace in other units.

Regardless of the choice of assessment tools,the same principles should apply; continuous,objective, holistic assessment taking into accountmonitoring data, invasive information from bloodgases and the clinical picture. Ongoing assessmentis a vital part of care including the airway, effec-tiveness of ventilation, and the effect on othersystems such as cardiovascular status and renaloutput. Also important are the observation ofcontinuous bilateral chest ‘bouncing’, chest x-rayinterpretation to ensure lung integrity and obser-vation of lung volumes and blood gas analysis. Iwas made aware of the potential complications ofHFOV such as lung over-distension, exacerbation oflow blood pressure due to high MAP and potentialair leaks.

118 H. De Jesus, J. Petty

Therefore, assessment should take thesepotential side-effects into account. It was alsoessential that I closely observed the stress levels ofboth Baby H and the family to ensure that comfortwas promoted as much as possible; a vial elementof family centred care.

Promoting comfort

The baby in this case study was given musclerelaxants temporarily to stabilise the ventilationstatus during the acute critical phase whenrequirements were particularly high. The baby withPPHN can be challenging in view of resulting pooroxygenation and any increase in handling or changein interventions can quickly exacerbate stress. Inpractice, such agents should be administered forstabilising and optimising ventilation only for, as inthis case, a short period of transfer to a tertiarycentre. It is imperative that in this situation, a babyis also given a simultaneous morphine infusion and/or sedation since one who is temporarily ‘para-lysed’ is unable to exhibit the same pain cuesmaking assessment more difficult. With respect toHFOV, it must also be remembered that this isa non-physiological method of ventilation which isnot natural so potentially increasing stress.

Therefore, promoting a sound level of sedationis particularly pertinent in such babies as well asthe need for appropriate and ongoing analgesiarequired for the significant number of proceduresassociated with intensive care.

The area of pain management as well as the useof muscle relaxants raises important ethical issuesin intensive care neonatal practice. Ethics demandthat it is a health professional’s duty to do goodand minimise harm to a patient, (Johnstone, 2008)along with their families.

The principle of beneficence demands that painshould not be inflicted to the baby. However, inthe ultimate intent of beneficence, some inter-ventions such as ventilation and other invasiveprocedures were painful but necessary. In lieu ofnon-maleficence, it was my duty to lessen the painand minimise the potential harm. Parents mayserve as advocates for their baby but this may notalways be realistic or ideal due to their own stresslevels. Hence, the duty of beneficence and non-maleficence lies more heavily on the practitionersshoulders. Medical ‘paternity’ is relevant here(McHaffie et al., 2001). On a practical level,beneficence is satisfied at this point by providingtherapeutic comfort care. Non-maleficence isthrough providing adequate pain relief during

procedures, safe administration of the pain medi-cation and limiting unnecessary procedures in linewith minimal handling. During the cares, closeassessment of pain cues such as vital sign changes,increased oxygen requirement and clinical cueswas necessary to indicate if the baby was in pain ordiscomfort. I have also internalised that ‘paralysis’by the administration of muscle relaxants is notsedation or analgesia.

As ‘paralysis’ can actually lessen the cues to thebaby’s pain, hence, more adept nursing assess-ment is essential (Walden and Carrier, 2009).

Care of the family

No case study should ever be complete withoutconsideration of the parents within holistic care inline with family centred care. Inclusion of thefamily was integrated throughout the care of BabyH and this should always be the case. Parentsshould be considered in the decision making oftheir baby, their needs must be recognised andstrategies employed to minimise the negativeeffects of an admission to the neonatal intensivecare unit (NICU). HFOV specifically is a modeemployed as a ‘rescue’ therapy for very sick babiesand it is a strategy that looks ‘unnatural’. Thisrequires explanation clearly with sound rationaleso that parents grasp the reasons for it and canwork to cope with the situation in the best way.

A recent review by Lanlehin (2012) identifies themany factors associated with information satis-faction in parents within the NICU recognising thevital need for involvement in decision making andappropriate information giving. Other researchconfirms the need for clear information, adequatefacilities and integration of family inclusion asstrategies to assist parents at this very difficulttime (Tran et al., 2009; Redshaw and Hamilton,2010; Mundy, 2010).

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Conclusion

Practice and knowledge divorced from reflectioncages progress. This reflection although limited,has showed me its transformative power. Thelearning curve in relation to the care of a babyrequiring HFOV has taken a steeper edge. Myprevious knowledge and myopic view on the issuessurrounding this ventilation technique has beenenhanced greatly by this experience. It has alsomade me realise that continuous updating ofevidence based knowledge and practice is essentialto address the gaps in my current level of under-standing and further the decision making processaway from novice towards competent and eventu-ally the proficient practitioner level. Armed withthis experience has increased my confidence toparticipate in team decisions regarding this type ofventilation andmanagement of complex ventilationrequirements in the NICU. In addition, concurrentwith the many clinical issues associated with thiscase is the knowledge of ethical principles that areperpendicular to my role along with the importanceof an awareness of family centred care.

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