1995 OPEN FORUM Abstracts
NEGATIVE PRESSURE VENTILATION IN RSV: A CASE SUMMARY
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., Maureen O'Rourke, MD, The Children's Hospital of Philadelphia, Philadelphia, PA
PATIENT DATA AND CASE SUMMARY: A 10 month old child with a history of wheezing once prior, was transferred to our Emergency Department from an outlying hospital. Chief complaints included fever for two days, decreased food intake, vomiting, cough and increased work of breathing. The child had been diagnosed with otitis media by his Primary Medical Physcian a few days prior to presentation. Upon arrival to our hospital, the patient was tachypneic and tachycardic. He was wheezing and demonstrated a significant oxygen requirement. Home medications included amoxicillin and ventolin syrup. This patient was treated in the Emergency Department with continuous aerosolized albuterol at 2 cc/hr, FiO_2 1.0, ampicillin and a NSS bolus. Laboratory data confirmed that the patient was in Impending Respiratory Failure and was positive for RSV. Initial arterial blood gas analysis revealed 7.34/47/137/25 on FiO_2 1.0. Chest x-ray revealed peribronchial thickening with hyperinflation of lung fields, right upper lobe and left lower lobe pneumonia. The patient remained tachycardic and tachypneic with retracting and nasal flaring despite interventions. A few hours after presentation he began to desaturate to 90% while on FiO_2 1.0. Upon arrival to the PICU, the patients respirations were 70-100, heart rate was 174-189, and oxygen saturation was 97% on FiO_2 1.0. It was considered that this patient would have only required an artificial airway in order to provide mechanical ventilation. Since this patient's natural airway was in tact, we attempted to provide ventilatory support with Continuous Negative Pressure. This patient was placed in the Port-A-Lung, a pediatric negative pressure ventilator, and assisted with a continuous negative pressure of 20 cm H_2O. Three hours after Continuous Negative Pressure was initiated, his oxygen requirement was .35, respiratory rate 70, heart rate 145, and blood pressure 105/69. The patient remained on continuous aerosolized albuterol while in the negative pressure for 12 hours, after which time the albuterol was weaned to Q2H. Twenty-four hours after the initiation of continuous negative pressure, clinical data and physical assessment indicated improvement in ventilatory status. Trials out of the Port-A-Lung were begun. Respirations were 50-60, heart rate 150, oxygen requirement .25 via aerosol mask. Chest x-ray revealed persistent peribronchial thickening with interval worsening of right upper lobe and left lower lobe atelectasis vs. infiltrate. Forty-eight hours after admission to the PICU, the patient required oxygen at 1.5 liters via nasal cannula to maintain oxygen saturations greater than 95%. He remained out of negative pressure, breathing comfortably at 40-60 times a minute, heart rate was 129-142. Seventy-two hours after admission to the PICU the patient was transferred to the Regular In Patient Care Area on 1.5 liter nasal cannula and Q3H albuterol treatments. The patient gradually weaned off his oxygen and was discharged after 7 days (168 hours). SIGNIFICANCE OF THE CASE: Continuous Negative Pressure Ventilation was a safe and effective intervention for this 10 month old patient with RSV pneumonia/Impending Respiratory Failure.