The Science Journal of the American Association for Respiratory Care

1999 OPEN FORUM Abstracts

UTILIZING KINETIC AND PERCUSSIVE THERAPIES TO IMPROVE PULMONARY OUTCOMES OF A PEDIATRIC PATIENT: A Case Study.

Theresa Ryan Schultz, BA, RRT, CPFT, P/P Spec., Roberta Hales, BS, RRT, P/P Spec., Ann Marie Wallack, AS, RRT, P/P Spec., Kathleen Sloan, BS, RRT, P/P Spec., Denise Garvey, AS, CRT, P/P Spec., Mark Helfaer, MD. The Children's Hospital of Philadelphia, Philadelphia, PA.

A 5 mos. old with a history of Hemophagocytic Syndrome was admitted to the PICU in respiratory distress requiring 60% oxygen via tent. She was tachypneic with a respiratory rate of 145, and tachycardic to 176. Within two days of this ICU admission, the patient became acidotic and hypoxic, requiring nasal tracheal intubation. PaO2/FiO2 (P/F) one hour post intubation and mechanical ventilation was 64. This patient received a Bone Marrow Transplant on the third day of this ICU admission. After eleven days of mechanical ventilation, the patient was weaned to extubation. Negative inspiratory force was -50 cm H20 prior to this brief trial. This patient was re-intubated with 3.5 mm tracheal tube secondary to extrathoracic gasway obstruction. One day post re-intubation this patient's P/F remained <250 (233). She progressively deteriorated over the next few days requiring volume replacement for hemodynamic instability. Chest x-ray eventually revealed worsening of fluffy infiltrates/nodules. Follow-up CT Scan showed complete atelectasis of the left lung with mediastinal shift towards the left and right scattered pulmonary nodules. Amphotericin was started for a presumed fungal infection. Fluids and dopamine were administered for continued periods of cardiovascular instability. Pulmonary toilet with manual bilateral rotation and percussion followed by suction was done every 2-4 hours. In spite of these efforts this patient's P/F fell to 183 over the next few days. It was decided that this patient might benefit from the kinetic and percussive therapies available on the KCI PediDyne Crib1. The patient was transitioned to this crib without incident. Continuous lateral rotation/kinetic therapy @ 30-40 degrees with percussion every 4 hours were the therapies utilized. Within twenty-four hours of receiving these therapies, the patient's P/F increased to 209. There were no other changes in ventilating pressures or minute ventilation. Within 72 hours of initiating therapy, this patient's P/F increased to 251. By the 90th hour of therapy, the P/F increased to 366. The patient then began to wean from the mechanical ventilator and was successfully extubated to a 2 liters per minute nasal cannula 4 days later. Chest radiograph showed no focal radiodensities at this point in time. She was transferred out of the ICU one day after successful extubation.

Day of mechanical ventilation Therapy PaO2/FiO2 % change
11 - Failed extubation -
15 manual rotation/percussion 183 -
15 Kinetic therapy started - -
16 Kinetic therapy/percussion 209 12%
18 Kinetic therapy/percussion 260 30%
19 Kinetic therapy/percussion 366 50%
23 Kinetic therapy/percussion Successful extubation -

Conclusion: Kinetic and Percussive Therapies available on the PediDyne Crib seemed to be a valuable adjunct to this patient's course of treatment. For these reasons, we have developed a prospective crossover design study to investigate this objectively.

1. McKay C. A Supplement to RN. Best Practices: Reducing nosocomial pneumonia. Feb. 1999.

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