The Science Journal of the American Association for Respiratory Care

1997 OPEN FORUM Abstracts

A Novel Approach to Ventilating a Neonate During Hyperbaric Oxygen Treatment: A Case Report

R Scott RCP RRT, L Langga RCP RRT, D Sample RCP RRT, P Tran MD, D Bland MB, T Lo MD, Loma Linda University Medical Center, Loma Linda, California.

Introduction: There are few reported cases of neonates receiving Hyperbaric Oxygen (HBO_{2}) treatment, and no known reports of any being mechanically ventilated during this process. We present a case of a mechanically ventilated infant needing adjunctive HBO_{2} after failing conventional therapy for severe necrotizing fasciitis (NF) and abdominal wall infection. Case Summary: A 12-day old caucasian female was referred for adjunctive HBO_{2} treatment. The patient developed NF of the anterior abdominal wall refractory to local wound care, intravenous (IV) antibiotics, and surgical intervention. Abdominal complications led to deterioration of the respiratory status, and the patient was placed on mechanical ventilation. The patient was referred for HBO_{2} to treat the NF. The standard HBO_{2} ventilator system was deemed insufficient for the neonate's needs. The decision was made to have a respiratory care practitioner (RCP) manually ventilate the infant during compressions. A Laerdal pediatric resuscitation bag and valve system was selected for ventilating the infant. The RCP manually ventilated the infant during the entire 60 minute regimen. Ventilation, vital signs, and temperature were monitored during each compression. Our patient underwent 22 HBO_{2} treatments at two atmospheres absolute. There was no complication from HBO_{2}. The patient received a 21 day course of IV antibiotics and subsequent successful abdominal wall closure. Discussion: There has been considerable experience in the use of mechanical ventilation in a monoplace HBO_{2} chamber with larger children and adults, but no known reported cases involving neonates. In our facility, the Sechrist 500A ventilator is used with the Sechrist monoplace HBO_{2} chamber. The 500A is a time cycled, pneumatically controlled volume limited ventilator. Tidal volume (VT) is set by the inspiratory to expiratory ratio and flow rate. Tidal volume is affected by changes in chamber pressure, lung compliance, and inlet pressure. The following limitations make the 500A difficult to use with neonates: compression and decompression significantly alter VT; the inspiratory time is limited to > 1 sec; the accuracy of the turbine style spirometer is insufficient. These conditions challenged us to develop an alternative method to ventilate our patient. Thombs et al. suggested manual ventilation as a method to effectively ventilate an infant undergoing HBO_{2} treatment. We chose to place a RCP in the chamber to manually ventilate the infant. The RCPs provided effective ventilation, maintain airway patency, and assessed the patient's clinical status throughout each compression. Monitoring tools were limited. Maintaining a neutral thermal environment was a major concern. Cotton blankets were used to conserve body heat and reduce convective and evaporative heat loss. The infant's temperature was taken regularly using glass, non-mercury thermometers. Selection of the diving RCP was determined on a voluntary basis. The RCPs were in good health and free of middle ear problems, colds, or sinus infections. Conclusion: Ventilation of an infant in the monoplace HBO_{2} chamber is a challenge. Based on our experience, manual ventilation of a neonate is a viable alternative in safely ventilating an infant receiving HBO_{2} in a monoplace chamber. Our case highlights the need for a mechanical ventilator capable of providing ventilatory support of neonates undergoing HBO_{2} treatment.


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