The Science Journal of the American Association for Respiratory Care

1998 OPEN FORUM Abstracts

AIRWAY PRESSURE RELEASE VENTILATION FOR A PEDIATRIC PATIENT ON ECMO: A CASE STUDY

Suzanne M. Durning BS, RRT, P/P Spec, Theresa R. Schultz BA, RRT, CPFT, P/P Spec., Linda A. Napoli, BS, RRT, RPFT, P/P Spec., R.I. Godinez, MD, PhD. The Children's Hospital of Philadelphia, Philadelphia, PA

Background: This is a one year old, 9.6 kg former 32 week gestational age twin male who was admitted to our Asthma Care Unit and treated with steroids and continuous albuterol. He was diagnosed with parainfluenza pneumonia and was transferred to the Pediatric Intensive Care Unit secondary to worsening respiratory distress despite aggressive bronchodilator therapy and steroids. The patient was intubated and mechanically ventilated upon transfer to the PICU. He subsequently developed bilateral pneumothoraces, requiring four chest tubes. He was placed on Veno-Arterial ECMO: pump flow 1.2 liters per minute, sweep flow 1 liter per minute, FiO_{2} 1.0. Over the next few days, chest x-rays revealed worsening radiodensity with diffuse white out. While this is a common finding for patients on ECMO, conventional treatment such as increasing PEEP and lung conditioning were ruled out secondary to severe air leak and increased peak airway pressures. Mechanical ventilation was manipulated with the goal to minimize the perpetuation of lung injury. In an attempt to realize the benefit of spontaneous breathing while utilizing minimal airway pressures, Airway Pressure Release Ventilation (APRV) was initiated at 1650. Settings were manipulated while attempting to maximize SvO_{2} (an indwelling catheter was in the ECMO circuit). The final settings and corresponding ABG results as follows:

1400 RR Ti FiO_{2} Peak

SIMV 10 bpm 1sec 1.0 35 cmH_{2}O

ABG pH pCO_{2} PaO_{2} HCO_{3}

1400 7.47 37 62 27

0300 RR T_{1}=3sec FiO_{2} Pmax

APRV 10 bpm T_{2}=3sec .21 25cmH_{2}O

0330 pH pCO_{2} PaO_{2} HCO_{3}

ABG 7.38 40 67 24

1400 PEEP MAP

SIMV 5cmH_{2}O 9cmH_{2}O

ABG B.E. SaO_{2}

1400 4.5 92%

0300 Pmin MAP

APRV 5cmH_{2}O 15cmH_{2}O

0330 B.E. SaO_{2}

ABG -0.6 93%

Hemodynamic status remained unchanged with BP 83/64, MAP 60, heart rate 114 per minute. Subsequent chest x-ray results over the next 48 hours revealed improvement in the opacification of the lung fields bilaterally and resolving pneumothoraces.

Conclusion: This application of APRV enabled us to achieve adequate ventilation and oxygenation at lower inflating pressures for this spontaneously breathing patient.

The 44th International Respiratory Congress Abstracts-On-DiskĀ®, November 7 - 10, 1998, Atlanta, Georgia.

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