The Science Journal of the American Association for Respiratory Care
Introduction: Utilizing conventional mechanical ventilation to support patients with lung or airway injury creates the potential for additional pulmonary damage. Independent lung ventilation (ILV) has been advocated to limit further injury to the diseased lung segment and avoid barotrauma/volumtrauma to healthy segments. We describe a case of synchronized ILV in a pediatric patient with airway injury. Case Summary: A previously healthy seven year old male weighing twenty-eight kg presented to the emergency department in respiratory distress with wheezing and stridor. A chest radiograph revealed a mediastinal mass, and a biopsy was performed which revealed anaplastic T-cell lymphoma. While intubated and ventilated for tracheal compression, he underwent three days of radiation therapy to facilitate tumor shrinkage. A right-sided air leak developed secondary to a bronchopleural fistula, therefore he was re-intubated using a double lumen endotracheal tube (ETT) and the left lung was mechanically ventilated with low Vt while the right lung was placed on CPAP. Bronchoscopic evaluation of the airway revealed a 5 cm tracheal tear extending from the end of the trachea into the right mainstem and right upper lobe bronchus. Post-operatively, hypercarbia and hypoxemia developed. A fogarty catheter was placed into the right mainstem to prevent ventilation to the right lung, and a 5.5 cuffed ETT was placed into the trachea to ventilate the left lung. Ten days later, the left and right mainstems were selectively intubated with individual cuffed ETTs through a tracheostomy stoma. ILV was instituted using two Siemens Servo 300 ventilators in the pressure regulated volume control mode. Both lungs received a rate of 24, Peep of 5 cm H2O, Fi02 of 0.45. The exhaled Vt was 270 mls for the left lung and 70 mls for the right lung. He remained stable, sedated, and paralyzed on ILV for four weeks before undergoing a right upper and middle lobectomy with repair of his tracheal defect. He returned from the operating room nasally intubated, and was extubated in five days. This patient spent sixty-eight days in the PICU, and sixty of those days on a ventilator. Three weeks after being transferred to the floor, he was discharged home to receive outpatient chemotherapy. Discussion: We believe the patient benefited from ILV in several ways: 1) it allowed the injured airway to be bypassed until repair could be accomplished, 2) safe ventilation was delivered to the healthy lung, and 3) more invasive support (i.e. ECMO) was avoided.