1995 OPEN FORUM Abstracts
Air Transport Of A Ventilated Infant Requiring Nitric Oxide Therapy - Case Study
Micheal Frentzel, RRT, MHA, T. Pearson-Shaver, MD, Department of Pediatrics, Medical College of Georgia, Augusta, Ga.
We report a case study in which the successful air transport of a patient receiving nitric oxide played a key role in the patient's outcome. As experimental use of nitric oxide (NO) gas as an inhaled pulmonary vasodilator becomes more widespread the potential for transport of patients requiring NO could become more frequent. This patient had an initial diagnosis of coarctation of the Aorta which was repaired at approximately two weeks of age. At 26 days post surgical repair the patient still remained ventilator dependent requiring hyperventilation and inotropic therapy for the treatment of pulmonary hypertension. At this time NO was initiated and improvement in PaO2 was seen. For the next seven weeks the patient received NO 50 to 80 ppm via the Servo 900C ventilator. NO and blended gas were titrated into the low flow port of a Servo 900C ventilator. NO/NO_2 levels were monitored on the inspiratory limb of the circuit using a Bedfont NO/NO_2 EC90 monitor. Attempts to wean the patient from NO failed. A diagnosis of Pulmonary Vascular Obstructive Disease was confirmed. The determination was made that a lung transplant was the patient's only option for long term survival. Since our institution did not offer this service we would have to air transport the patient to a facility which did. The patient would require NO therapy during the transport to maintain oxygenation. Several problems involving the transport became evident. The equipment itself was cumbersome, NO/NO_2 exhaust from the ventilator and resuscitation bag required a scavenging system, careful titration and monitoring of inhaled NO gas would be needed during transport. The patient monitors, NO/NO_2 monitors and Servo ventilator were mounted on an adult stretcher with the patient. We also took a topaz battery, cylinders of oxygen, air and NO for the mechanical ventilator during the transport. In the event that the ventilator malfunctioned we modified an Ambu resuscitation bag equipped with a closed reservoir and one-way valve proximal to the bag itself. Delivered NO/NO_2 levels were measured in the modified resuscitation bag. The exhaust from the resuscitation bag was scavenged via a suction system to prevent exposure of NO/NO_2 to personnel. A medically equipped Hawker jet was used for the transport. The jet's suction system emptied outside of the patient cabin so personnel were not exposed to the scavenged NO/NO_2 from the ventilator or resuscitation bag. The jet cabin and ambulance were monitored for the presence of NO/NO_2 during transport, levels were well within OSHA standards. The transport was successful but not without difficulty. Saturations per oximetry remained greater than 90% throughout the transport. Moving all the equipment as a unit required coordinated effort. The ventilator battery did not last the entire trip and manual ventilation was necessary for the last 15 minutes of the transport. Delivered NO level was monitored at 50 to 60 ppm during mechanical ventilation and manual resuscitation. A lung transplant was done within a few days of the patients transport to the facility. Six weeks after the transplant the patient was completely weaned from mechanical ventilation, and then discharged from the hospital several weeks later. We believe a safe transport to the facility was key for this patient's outcome, but not without some obstacles. In the future a smaller battery powered ventilator that could deliver NO would be more ideal. It would also have been helpful to have had some kind of built in scavenging system. Transport vehicles should be equipped with an electrical source, suction source and 50 p.s.i. gas source. We believe that with improvements transporting patients requiring NO could be made safer and easier in the future.