The Science Journal of the American Association for Respiratory Care

2002 OPEN FORUM Abstracts

EARLY INTERVENTION WITH HFOV AND APRV FOR A PEDIATRIC PATIENT WITH ASPIRATION PNEUMONITIS: A CASE STUDY.

Roberta L. Hales BS, RRT, RN, Suzanne M. Durning BS, RRT, Karen Bonn AS, CRT, Vinay Nadkarni MD; The Children?s Hospital of Philadelphia, Philadelphia, PA

A 9-month s/p 30-week premature infant presented with fever, vomiting, diarrhea and circulatory shock. He required volume resuscitation and tracheal intubation in the emergency department. He was noted to have formula beneath the vocal cords on tracheal intubation with a 4.0 uncuffed tracheal tube. Twenty four hours later, the patient was supported with a Siemens Servo 300, Pressure Regulated Volume Control (PRVC), FiO2 35-50%, Vt 100, RR 25, PEEP 6cmH20, Ti .75 seconds and a peak inflating pressure of 38-41 cmH20. He was on a pancuronium and fentanyl infusion, with intermittent lorazepam sedation and managed with permissive hypercapnea target of PCO2 50-60 torr. In addition, he required 10 mcg/kg/min dopamine, crystalloid boluses, and 10 ml/kg PRBC?s in a 24-hour period to treat low blood pressure/hypoperfusion. CXR was consistent with aspiration pneumonitis and ARDS. During the course of the day, the patient had an increasing oxygen and ventilation requirement. He was ventilated using a protective lung strategy of 6ml/kg Vt to limit the peak inflating pressure to 35 cmH2O. PEEP maneuvers determined a best PEEP of 10 cmH2O.

Blood gas results were as follows:

PRVC Settings pH PCO2 PaO2 HCO3 B.E. SpO2
Vt 100ml, RR 25, PEEP 6cmH2O, FiO2 1.00, PIP 38-41 cmH2O 7.24 62 84 25.6 -3.0 94
Vt 85ml, RR 22, PEEP 10 cmH2O, FiO2 .35, PIP 35-37 cmH2O 7.15 83 70 28.4 -2.8 89
Vt 85ml, RR 28, Peep 10 cmH2O, FiO2 35, PIP 35-37 cmH2O 7.32 65 83 34 +7 90

Despite the ability to achieve acceptable blood gases on conventional ventilation, we transitioned the patient to the Sensormedic HFOV 3100A, as an early intervention, rather than a rescue strategy. This decision was made in anticipation of the need for increasing ventilatory support and V/Q mismatching, in an attempt to minimize iatrogenic lung injury.

HFOV settings pH PCO2 PaO2 HCO3 B.E. SpO2
Paw 25, Delta P 55 cmH2O, Frequency 7 Hz, FiO2 .40, Ti 33% 7.30 73 81 36 +8 94%
Paw 25, Delta P 55 cmH2O, Frequency 6 Hz, FiO2 .40, Ti 33% 7.44 53 114 34.7 9.1 95%

Blood gas results on the HFOV were as follows:

The patient was maintained paralyzed and sedated on the Sensormedic HFOV for four days and subsequently transitioned to the Drager Evita 4 in APRV, Phigh 35, Plow 12, Thigh 2.5 seconds, Tlow 1.5 seconds. Following transition to APRV, paralysis was discontinued.

APRV settings pH PCO2 PaO2 HCO3 B.E. SpO2
Phigh 35, Plow 12,Thigh 2sec.,Tlow 1 sec,FiO2 .45,Vtexh 110ml 7.38 49 111 29 3.3 100
Phigh 35,Plow 12, Thigh 2sec, Tlow 1 sec, FiO2.25, Vtexh 140 ml 7.56 30 104 26 4.6 100
Phigh 30, Plow 12,Thigh 2 sec,Tlow 1sec, FiO2 .25 Vtexh 120 ml 7.50 34 121 27 4.3 100
Phigh 26, Plow 9 Thigh 2 sec, Tlow 1sec, FiO2 .30, Vtexh 100 ml 7.48 42 122 30 5.8 100
Phigh 24 , Plow 9, Thigh 2sec, Tlow 1 sec, FiO2.30, Vtexh 98 ml 7.42 46 140 29 4.4 100

Blood gas results were as follows:

The patient was transitioned to SIMV with AutoFlow per physician preference and subsequently weaned to extubation in three days. The patient was weaned from oxygen one day following extubation.

Discussion: Many strategies can minimize iatrogenic lung injury associated with aspiration pneumonitis and ARDS. Early intervention with alternative modes of ventilation (HFOV and APRV) can be effective. HFOV with paralysis/sedation facilitates lung recruitment and early transition to APRV allows return to spontaneous ventilation without paralysis and derecruitment of alveoli. This ventilatory strategy resulted in a positive patient outcome and may be a useful management strategy.

OF-02-165

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