The Science Journal of the American Association for Respiratory Care

1998 OPEN FORUM Abstracts

TREATMENT OF SEVERE TRAUMATIC BRONCHOPLEURAL FISTULA WITH UNILATERAL HIGH FREQUENCY JET VENTILATION - CASE PRESENTATION

John Emberger BS RRT, Andrew Ginn RRT, Rick Ermak RRT, Dennis Witmer MD, Marc Zubrow MD, Department of Respiratory Care, Christiana Care Health System, Newark DE.

Background: High frequency jet ventilation (HFJV) and independent lung ventilation (ILV) have been used to treat severe pulmonary air leaks (1,2,3). We present a case of severe bronchopleural fistula which required both ILV and HFJV, also called unilateral high frequency jet ventilation (UHFJV). Case Summary: Fifty four year old male presented with a self-inflicted gunshot wound to the right chest wall. Volume ventilation would not achieve oxygen saturation above 84%. Pressure control ventilation (PCV) was initiated with rate = 18 breaths/minute, 100% FiO2 and +5 PEEP (ABG: pH = 7.31, PaCO2 = 48 torr, PaO2 = 65, SaO2 = 88%). Chest X-ray showed metallic fragments, shattered ribs, and parenchymal opacity consistent with severe pulmonary contusion of the right lung. Within eight hours ILV was initiated. A tracheostomy was done to place a double lumen tube. Right lung ventilator settings were: Assist Control mode, rate = 4 breaths/minute, no PEEP. Left lung ventilator settings were: PCV, rate = 16 breaths/minute, +7 PEEP. The ABG improved to: pH = 7.42, PaCO2 = 45 torr, PaO2 = 122 torr, SaO2 = 98% on 100% FiO2. The air leak noticeably decreased. The patient deteriorated over the next day (PaO2 = 60 torr on 100% FiO2) as the lung injury worsened on chest X-ray. The decision was made to initiate UHFJV on the right lung (HFJV on the right lung and PCV on the left lung). The ABG improved (pH = 7.48, PaCO2 = 37 torr, PaO2 = 115 torr). A decrease in the air leak was again noted. The patient was maintained on UHFJV for 11 days. When the patient was converted back to conventional ventilation on day 13 after admission, the double lumen tube was pulled from the tracheostomy site and a regular tracheostomy tube was placed. The patient was placed on Pressure Support Ventilation and began to wean. The patient was weaned from the ventilator to tracheostomy collar 17 days after conversion to conventional ventilation (day 30 after admission). Three days later the patient was decannulated. Three days after decannulation (day 36 after admission) the patient was discharged. Discussion: This is an example of a patient that benefited from the use of UHFJV (both ILV and HFJV). Cases of UHFJV are reported in the literature (1,2,3) and we wanted to describe the positive results that we experienced with this case.

References:

1. Wipperman C, Schranz D, Baum V et al. Independent right lung high frequency and left lung conventional ventilation in the management of severe air leaks during ARDS. Paediatric Anaesthesia 1995;5(3):189-192.

2. Mortimer A, Laurie P, Garrett H, et al. Unilateral high frequency jet ventilation. Reduction of leak in bronchopleural fistula. Intensive Care Medicine 1984; 10(1):39-41.

3. Crimi G, Candiani A, Conti G, et al. Clinical applications of independent lung ventilation with unilateral high-frequency jet ventilation (ILV-UHFJV). Intensive Care Medicine 1986; 12(2):90-94.

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

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