The Science Journal of the American Association for Respiratory Care

2000 OPEN FORUM Abstracts

INDEPENDENT LUNG VENTILATION WITH CONVENTIONAL AND HIGH FREQUENCY OSCILLATORY VENTILATION

Harrison, Julie RRT; Cox, Timothy RRT; McCloskey, John MD A.I. DuPont Hospital for Children, Thomas Jefferson Medical College, Wilmington, De

Introduction: Independent Lung Ventilation (ILV) has an established role in the mechanical ventilation world, but users must be familiar with its complexities so it can be appropriately applied. ILV is shown to be beneficial for bronchopleural fistula, unilateral lung disease, massive hemoptysis and for thoracic surgery. Generally, ILV utilizes two like ventilators, but we present a case summary utilizing conventional mechanical ventilation and High Frequency Oscillatory Ventilation (HFOV) to recruit the right upper lobe of a patient with a upper respiratory infection (URI). Case Summary: WF, a 7-month-old, ex-28 week pre-mature baby with a 12 day history of URI symptoms was placed on antibiotic therapy at home. On the day 13, the baby had increased WOB, nasal congestion, cough, loose stools, normal amount of wet diapers, no fever or vomiting. The baby presented to the emergency room with SaO2 in the 80's, RR 80-100, retracting and flaring. Anterior/posterior chest X-ray showed RUL pneumonia. His past medical history revealed hypoxic encephalopathy and neurologic damage, gastro-esophageal reflux (GER), and a fundoplication. The patient was admitted with the diagnosis of right upper lobe (RUL) pneumonia secondary to aspiration. The baby was placed on high flow O2, Timentin, and a Beta Agonist via small volume nebulizer. On Day 2, the baby was intubated with a 3.5 endotracheal tube (ETT) for continued desaturations and placed on a Bird VIP (Thermo-Respiratory Group, Palm Springs, Ca.). On Hospital Day 3, both rigid and flexible bronchoscopy showed increased secretions from the right lung; but otherwise normal anatomy. During Hospital Days 3, 11 attempts were made to increase the Peak End Expiratory Pressure (PEEP) level from 5 to 6 to 8 to recruit RUL. The left lung gradually became overdistended while the RUL remained solidified. The PIP's on the ventilator were then increasing to 37-39 cmH2O. At this point, WF was placed on a High Frequency Oscillatory Ventilator (HFOV) (Thermo-Respiratory Group, Palm Springs, Ca.) starting at Mean Airway Pressure (MAP) 20-24, Amplitude (AMP) 64-80, Frequency (Hz) 10, Fractional Inspired Oxygen (FiO2) .60 The CXR was still showing overdistention of the left lung and consolidation of the RUL, and the patient was still having periods of desaturation. The patient was changed back to conventional ventilation, and the decision was made to initiate ILV. The patient was intubated with two 3.0 ETTs; one in the right mainstem for the HFOV and one in the trachea for conventional ventilation (CV). Settings were as follows: HFOV: AMP 52, Hz 10, MAP 15®18®12, FiO2 .37-.40; Volume Cycled: IMV mode, RR 36®30, Vt. 80cc, PEEP 7, FiO2 .40-.30, PIP's ranged from 20 to mid 30's with MAP's 10-12.7. The patient remained on Independent Lung Ventilation for 3 days, at which time he was then changed back to conventional ventilation for 12 days. He was then extubated, and within the next 10 days, was gradually weaned to room air and discharged. Discussion: In conclusion, the decision to independently ventilate each lung was made to prevent barotrauma to the left lung, while recruiting the pneumonic RUL, resulting in successful recruitment of the RUL and prevention of barotrauma.

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