2000 OPEN FORUM Abstracts
INTRAPULMONARY PERCUSSIVE VENTILATION IN THE TREATMENT OF THE SMOKE INHALATION IN THE PEDIATRIC PATIENT
Kathleen Deakins RRT. Robert Chatburn RRT, FAARC
INTRODUCTION: Smoke inhalation injury to the airways can cause insult to the pulmonary and other organ systems. The severity of the insult is dictated by the pulmonary involvement. Pulmonary edema can be induced by changes in the microcirculation and activation of polymorphonuclear cells along with the production of free radical oxygen molecules. The most serious pathologic change occurring from smoke inhalation is the reduction of respiratory epithelium and the development of tracheobronchial casts. Intrapulmonary Percussive Ventilation (IPV) has been used in the adult population on patients with smoke inhalation to promote mobilization of retained secretions to remove tracheobronchial casts and improve atelectasis caused by obstruction from secretions. An increase in oxygenation has been associated with the reduction of ventilation/perfusion mismatch as atelectasis improves.
CASE SUMMARY: The subject is a five year old female who presented to our institution with smoke inhalation evidenced by soot markings on the face. The patient received CPR due to cardiopulmonary arrest, was intubated and placed on mechanical ventilation. Initial chest radiographs revealed peribronchial thickening and RUL collapse. Secretions suctioned were described as carbonaceous, thin and in small quantities. Five hours post admission, IPV was initiated via endotracheal tube using 9cc of normal saline lavage. IPV peak pressure was set equal to the that of the ventilator (25 cmH2O). The IPV frequency was set at 160 cycles per second. The volume of carbon-containing secretions obtained during suctioning increased. Tracheobroncial casts requiring additional lavage during suctioning were also observed. Secretions became clear after six treatments (24 hours later). Chest radiographs showed an improvement in atelectasis. Mechanical ventilation was discontinued 76 hours after admission. The patient was transferred out of the pediatric intensive care unit on day four and discharged from the hospital on day six. Discharge from the hospital was accomplished without need for additional respiratory support.
DISCUSSION: Previous studies done at our institution (Respir Care 1999;44:1248) have shown that IPV is a safe and effective treatment that improves atelectasis in pediatric intubated patients. IPV has been shown to mobilize and facilitate the removal of retained secretions, and increase the deposition of aerosolized particles while improving oxygenation. In this case, the administration of IPV was used as an adjunct for airway clearance, improving mobilization and removal of secretions. We believe this facilitated weaning from mechanical ventilation, by improving atelectasis.
In summary, IPV seemed to be an important adjunctive treatment for this patient with smoke inhalation injury.