1999 OPEN FORUM Abstracts
CASE PRESENTATION IN THE USE OF THE 3100A OSCILLATOR IN ARDS.
Thomas Serrano, RCP,BS RRT, Mark Harris, RCP, RRT, Andy Bogy, RCP, RRT, Tony Marquez, RCP, CRTT, Mark Tamondong, RCP, CRTT, David Harris, MD, Mukesh Shah, MD. Presbyterian Intercommunity Hospital, Whittier, California.
This is a case presentation of a 48-year-old female who has a known case of Cerebral Palsy and seizure disorder. She presented to the emergency room with a chief complaint of abdominal pain. Subsequently, the patient underwent repair of a volvulus because of a large bowel obstruction. Postoperatively the patient was doing well and was sent to the general floor. The next day the patient presented with gurgling sounds because of upper airway secretion, although no respiratory distress was noted. The CXR showed no acute changes and her SpO2 was 95% on 3L/m NC. Two days later the patient was transferred to ICU due to increase O2 requirements, bronchial hygiene issues and seizure activity. The patient continued to improve after 5 days in ICU and was transferred to the general floor. The day after transfer the patient exhibited respiratory distress and increase WOB. Patient was tracheal suctioned for large amounts of bile material, subsequently was transferred back to ICU. ABG on 50% was PaO2 69 PaCO2 34 pH 7.43 BE -1.6 HCO3- 24 RR 40's. The patient was electively intubated and placed on Vt 700 PEEP 5 Fio2 47% AC 10 with a spontaneous rate of 17. Over the next 2 days the patient continued to deteriorate requiring sedation and paralyzation with increase ventilatory support. She was eventually placed on inverse ratio ventilation of 4:1 with MAP at 29 cmH2O, Vt 568 RR 12 Peep 10cwp Fio2 60%. On these setting the patient ABG was PaO2 48 Paco2 68 pH 7.20 BE 1.0 HCO3- 23.7. CXR showed diffuse air-space consolidation especially RLL. Hemodynamic support was achieved with dopamine at 18.9 mcg/kg/min for a BP of 100/50. Pcwp 14 Pulmonary Artery Pressures 40/22. Oxygen Index was 31 (Fio2 ´ MAP ´ 100/PaO2) on inverse ratio ventilation. After a lengthy discussion it was decided to initiate High Frequency Oscillator Ventilation (HFOV) via Sensormedic 3100A. Transcutaneuos monitoring was initiated and was allowed to stabilize prior to placing pt on HFOV. Initial Setting on HFOV were MAP 32cm H2O Inspiratory Time 33% Hz 9 FiO2 1OO% and Delta P 45. The initial Delta P revealed minimal chest vibration and was rapidly increase until chest vibration was improved and TcCo2 ceased to increase. The initial ABG on HFOV was PaO2 71 PaCO2 76 pH 7.20 BE 1.0 HCO3- 23.7 on MAP 32cmH2O Hz 9 Inspiratory Time .33% Delta P 65 Fio2 68% TcCO2 81. One hour after initiating HFOV a CXR was obtained which showed interval clearing of bilateral air space consolidation. The ABG results were PaO2 63 PaCO2 66 pH 7.27 BE 2.7 HCO3- 25.6 on MAP 32 inspiratory time 33% delta P 69 Hz 6 Fio2 65%TcCO2 68 OI 33. Dopamine drip was titrated at 18.9 mic/kg/min, BP 110/60, PAP 46/28 Pcwp 18. CXR continued to show improvement with total expansion of right lung. ABG results were PaO2 56 PaCO2 41 pH 7.49 BE 7.5 HCO3- 31 on MAP 28 inspiratory time 50% delta P 60 Fio2 45% OI 22. On the third day of HFOV the patient began to have mucus plugging with resultant intermittent difficulty in patient ventilation. Conclusion: What we demonstrated is that HFOV was beneficial in achieving lung volume recruitment, which resulted in total expansion of right lung within a short period of time. The FiO2 was lowered to 38% prior to developing mucus plugging with a MAP of 20. Hemodynamically, dopamine administration was titrated down from 18.9 mic/kg/min to as low as 3.7 mcg/kg/min. We discovered that secretions or more importantly secretion removal is an obstacle when using HFOV in adults. The design of the inline suction catheter connection, which is at a 90-degree angle, interferes with the ability to oscillate the patient. Removal of the inline suction catheter was necessary. Frequent disconnection from the oscillator, for suctioning may have resulted in alveolar collapse.