1995 OPEN FORUM Abstracts
Continuous Negative Pressure Vs. Nasopharyngeal Cpap In Rsv, A Case Study
Theresa Rvan Schultz, BA, RRT, P/P Spec., Linda Allen Napoli, BS, RRT, RPFT, P/P Spec., Lorraine F. Hough, MEd, RRT, P/P Spec., Andrew Costarino, MD, The Children's Hospital of Philadelphia, Philadelphia, PA
PATIENT DATA AND CASE SUMMARY: A 3 month old former 32 week premature infant was admitted to the hospital and diagnosed with RSV bronchiolitis. This patient had been hospitalized for the first one month of life, twenty-four hours of which she required positive pressure ventilation. After her initial discharge to home she was reportedly well until 2 days prior to admission to our institution. The patient was admitted to the Regular Inpatient Care Area for three days prior to her transfer to the Pediatric Intensive Care Unit (PICU). Physical assessment of this patient, at the time of transfer, included increased work of breathing, wheezing, flaring, retracting and decreased food intake. Chest x-ray revealed right upper lobe infiltrate vs. atelectasis. Laboratory data confirmed Impending Respiratory Failure. Initial arterial blood gas analysis revealed 7.34/54/52/29/+2/84% while on FiO_2 .3. Respirations were 70. Upon arrival to the PICU, the patient was placed on nasopharyngeal CPAP + 10 cm H_2O, FiO_2 .4, with continuous aerosolized albuterol at 2 cc/hr which was weaned to Q2H nebulizer treatments within 5 hours. This patient remained on CPAP + 10 cm H_2O, FiO_2 .4 for three days with respirations 52-70 and heart rate 186-200+. Over the course of these three days it was necessary to replace the nasopharyngeal tube four times secondary to airway plugging/displacement. Each time the nasopharyngeal airway needed to be replaced, the patient was compromised due to inadequate CPAP and O_2 delivery. This resulted in cyanosis, tachypnea, bradycardia and acidosis. At the end of the three days of nasopharyngeal CPAP the patient's Chest x-ray was consistent with diffuse bilateral hyperinflation, progressive bibasilar atelectasis with worsening right upper lobe air trapping and atelectasis. Due to the problems associated with nasopharyngeal CPAP, as noted above, Continuous Negative Pressure was considered as an appropriate substitute. Research has demonstrated that Continuous Negative Pressure and CPAP are physiologically equivalent. CPAP was discontinued after three days and Continuous Negative Pressure (-15 cm H_2O) via the Emerson Iron Lung, an infant negative pressure ventilator, was utilized. Nebulized albuterol treatments continued every two hours. Physical assessment of the patient while in the negative pressure revealed respirations 30-40, heart rate 150-170. On the third day of intervention with negative pressure, we began to give the child trials out of the Iron Lung. We increased the amount of time out each day as tolerated over the next three days. On day six of continuous negative pressure ventilation, the patient had been out of the iron lung for over twenty-four hours and was transferred to the Regular In-patient Care Area on 1.5 liter nasal cannula. Chest x-ray at that time revealed right upper lobe atelectasis stable with slight apical clearing, otherwise aeration was satisfactory. Two days after transfer back to the Regular Inpatient Care Area the patient was weaned to room air with oxygen saturations equal to 95%. The patient was discharged to home ten days after the institution of continuous negative pressure. SIGNIFICANCE OF THE CASE: Continuous Negative Pressure Ventilation appeared to be an appropriate alternative to nasopharyngeal CPAP in this patient.