The Science Journal of the American Association for Respiratory Care

1997 OPEN FORUM Abstracts

HIGH FREQUENCY OSCILLATORY VENTILLATION IN ARDS: A CASE STUDY

Theresa R. Schultz, BA, RRT, CPFT, P/P Spec., Linda A. Napoli, BS, RRT, RPFT, P/P Spec., Lorraine F. Hough, MEd, RRT, CPFT, P/P Spec., Gregory J. Schears, MD., The Children's Hospital of Philadelphia, Philadelphia, PA

Patient Data and Case Summary: This is a 5.5 kg, six month old infant, with a history of prematurity, gastroschisis, hyperalimentation hepatitis, ileal resection, multiple bowel resections and recurrent sepsis, who was admitted to our institution for nutritional rehabilitation. During this admission, the patient underwent a liver biopsy and colostomy closure. Subsequently, he developed sepsis and was transferred to our Pediatric Intensive Care Unit for further management. He quickly deteriorated to requiring intubation and mechanical ventilation. Medications delivered continuously at this time included dopamine, dobutamine and morphine. Chest x-ray revealed dense consolidation of the left upper lobe and patchy infiltrates throughout the remainder of the lung fields. Abdominal findings demonstrated that bowel loops were central and the flanks were bulging suggesting the presence of acites, further compromising our already challenged method of mechanical ventilation. One day post op, the patient progressed to Adult Respiratory Distress Syndrome. Permissive hypercapnea and PaO_{2} greater than or equal to 50 mmHg became acceptable. In order to achieve this goal, the patient was paralyzed and placed on Pressure Regulated Volume Control via the Siemens Servo 300. PEEP +10 cmH_{2}O, mean airway pressures (MAP) 26-31 cm H_{2}O, peak pressure +47 cm H_{2}O, V_{E} 220 ml/kg/min were necessary in order to maintain gas exchange. At this time, in the face of persistent acidosis, A-a DO_{2} of 504-554 mm Hg, and hypoxemia, PaO_{2}/FiO_{2} of 57, it was decided to place the patient on the Sensor Medics Oscillator 3100A. Initial settings were 10 Hz, 33% inspiratory time, MAP 34, amplitude 40. Two hours later, the PaO_{2}/FiO_{2} was 182 with A-aDO_{2} of 272. This realized benefit continued into the evening and throughout the patients ventilator course. Sixteen hours after being placed on the oscillator, the patient's PaO_{2}/FiO_{2} was 167 and his A-a DO_{2} was 195 mm Hg. Twenty hours later, the patient continued to wean. While on MAP of 21 cm H_{2}O, PaO_{2}/FiO_{2} was 289 with A-a DO_{2} 66 of mmHg. During this time frame, dopamine and dobutamine infusions were successfully weaned. Chemical paralysis and sedation continued. The following chart summarizes changes in ventilation parameters:

Mechanical Mode MAP FiO_{2} PaO_{2}/FiO_{2} A-aDO_{2}

ventilation hours

8 SIMV/PC 26-31 1 53 524

16 HFOV 34 0.65 182 271

29 HFOV 28 0.43 167 195

49 HFOV 21 0.27 289 66

Significance of the Case: High Frequency Oscillatory Ventilation appeared to be valuable in the treatment of this patient. This method of mechanical ventilation enabled the healthcare team to improve oxygenation and ventilation of this pediatric patient with ARDS.

OF-97-070

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