The Science Journal of the American Association for Respiratory Care
Introduction: This is a 2 year old female whose past medical history includes tracheostomy, secondary to trachiobronchomalacia, and reactive airways disease with new onset bronchiolitis/respiratory failure. She was admitted to our Pediatric Intensive Care Unit from an outlying institution where she had been decannulated, intubated and mechanically ventilated for thirty-six hours. Persistent hypercarbia and hypoxemia with ground glass appearance on chest roentgenogram were reported. Upon arrival, her ventilatory requirement of 189 cc/kg/min. corrected exhaled minute ventilation, PEEP 15 cm H2O, PIP 37 cm H2O and FiO2 1.0 yielded the following: pH 7.28, PaCO2 67.5, PaO2 77.5, HCO3 36.3, B.E. 10.3, PaO2/FiO2 (P/F) 78, Oxygenation Index (OI) 30. A cuffed endotracheal tube was later placed, due to continued leakage around the uncuffed tube.
Methods: During this admission, a multitude of interventions were trialed including terbutaline, versed, fentanyl and pavulon infusions, solumedrol, zantac, lasix, inhaled nitric oxide (NO) and Survanta administration via direct instillation.
Results: This graph shows varied responses to inhaled nitric oxide pre and post Survanta delivery with no other changes in patient intervention.
|Nitric oxide pre Survanta administration||P/F||% change||OI||% change|
|Admission (day 2 of mechanical ventilation-MV)||78||-||30||-|
|1 hr. into 1st NO trial (day 3 of MV)||72||No response||31||-|
|2 hrs. into 1st NO trial (day 3 of MV)||60||No response||37||-|
|6 hrs. into 1st NO trial||60||No response||35||-|
|(discontinued on day 3 of MV)|
|Survanta administration||P/F||% change||OI||% change|
|Pre surfactant administration (day 5 of MV)||71||-||37||-|
|Post surfactant administration (day 6 of MV)||72||No change||35||5%|
|Nitric oxide post Survanta administration||PF||% change||OI||% change|
|1 hr. into 2nd nitric oxide trial (day 6 of MV)||97||27%*||26||30%*|
|4 hrs. into 2nd nitric oxide trial (day 6 of MV)||97||27%*||26||30%*|
|8 hrs. into 2nd nitric oxide trial (day 6 of MV)||90||21%*||27||27%*|
|13 hrs. into 2nd nitric oxide trial (day 6 of MV)||98||28%*||22||41%*|
|*(20% change in the P/F or OI is considered a favorable response)|
Conclusions: Upon review of this patient's course of illness and response to therapeutic interventions, it seems inhaled nitric oxide after Survanta administration yielded a more favorable response than nitric oxide alone or Survanta alone.