The Science Journal of the American Association for Respiratory Care

1997 OPEN FORUM Abstracts

MOBILE VENTILATION SYSTEM FOR A PEDIATRIC PATIENT REQUIRING HIGH LEVELS OF PEEP AND CONTINUOUS FLOW: A CASE REPORT

Joseph Lewarski, RRT, James Stegmaier, RRT, RPFT, Diane Jereb, RRT Hytech Homecare, a division of Compscript, Inc. and Health Hill Hospital for Children Cleveland, Ohio

Introduction: Even with new homecare ventilator technology appearing in the market, achieving cost effective home care is a constant challenge. We report the modification of existing homecare technology to meet the needs of a homeward bound ventilator dependent patient with a large tracheal leak who required high PEEP and mobility.

Case Summary: A 3 year old female quadriplegic from C-1, C-2 fracture has severe tracheal and bronchial malacia which contributed to a left lower lobectomy and large air leak around the tracheotomy tube (further exacerbated during sleep and unresolved by changing size, brand or cuff style). During the acute care stay of almost 1 year, conventional volume ventilation failed due to loss of PEEP during the expiratory phase, but pressure ventilation was successful. To mimic constant flow and leak compensation while providing portable volume ventilation, we combined a PLV-100 (Lifecare) and a Remstar CPAP generator (Respironics) to create a closed IMV system. The CPAP generator is introduced into the circuit at the PLV-100 patient air outlet using a one-way valve, preceding the bacteria filter and cascade la humidifier. The CPAP generator pressure level is set at the same level as the external PEEP valve and may be titrated to assure consistent PEEP and flow. A pressure relief valve prevents inadvertent high pressures; water traps and hydrofilters manage the rainout. A low pressure alarm was placed in line and set 1 cmH_{2}0 below the prescribed PEEP level. The ordered settings were as follows: Vt 150ml, Mode IMV, Rate 24, F_{1}0_{2} .21, PEEP +10 cmH_{2}0. The patient's secretions remained unchanged between the mobile and traditional ventilation systems. Performance of the ventilator and alarms were not altered by the additional flow. Pressure waveform analysis of this system was compared against the PLV-100 alone and no difference could be distinguished. Exhaled V_{t} monitoring consistently revealed V_{t} between 150 and 200ml. The system was trailed for several months in ICU and rehabilitation hospital settings prior to discharge. The system was mounted on a wheelchair tray, equipped with manufacturers' adapters and powered by 12 volt battery. Family training occurred on this system and emergency procedures over a period of several months and the patient was discharged. The patient has been successfully managed at home for over 6 months with this system. No adverse events have occurred and the patient's pulmonologist states the patient is thriving.

Discussion: Our experience demonstrates that the use of volume ventilation in conjunction with a CPAP generator creates a closed IMV ventilation system capable of providing high levels of PEEP, leak compensation and portability for the ventilator dependent pediatric patient. Continued work in the area of using volume control on inspiration and pressure control on expiration may help develop a standardized protocol for integrating an external continuous flow source with conventional portable volume ventilation.

OF-97-006

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