2003 OPEN FORUM Abstracts
THE TRANSITION OF A SMALL AND CHALLENGING PEDIATRIC PATIENT HOME VIA THE PULMONETICS LTV 1000 VENTILATOR
Cynthia C. White RRT-NPS, John F. Hunt MD, Brian K. Walsh BS RRT-NPS RPFT, University of Virginia Hospital, Charlottesville, VA.
Introduction: One challenge faced by Respiratory Therapists in Pediatric and Newborn Intensive Care Units is the process of transitioning the small (<10 kg) and most challenging vent dependent patients to a home ventilator. There has been, and continues to be much advancement in the technology of home ventilators. Despite this fact, very few offer the features important to ventilating the pediatric patient such as continuous flow, flow triggering, adjustable rise time, flow termination, and newer modes of ventilation such as time cycled SIMV/ PC with PS. The Pulmonetics LTV 1000 offers most of these features, but there are little data to support its use for patients under 10kg. This case report demonstrates the ability to transfer a 5.2 kg infant with severe thoracic congenital abnormalities to the LTV.
Case Study: The patient was a former 36 week 2750g infant who was delivered via C-section and admitted to the NICU. He was initially on NCPAP at +7cmH20, but soon required intubation for respiratory distress. The patient had significant spinal malformations with a menigocystocele in the left posterior thorax and associated agenesis of the left lung with near complete absence of ribs on the left. His physiology was that of complete flail chest secondary to a concurrent left diaphragmatic hernia and no lateral chest wall bony support. The cystic mass was partly drained, and the diaphragm plicated. The mediastinum shifted prominently left and provided enough support to allow the infant to be extubated for several weeks. Subsequent to extubation, he suffered from frequent episodes of hypoventilation. The single main stem bronchus was noted to be malacic and positionally compressed when the baby was positioned right side down. Additionally, laryngomalacia was identified. At six weeks of age, a 3.0 Neo-Shiley tracheostomy tube was surgically placed. The patient tolerated rapid weaning from TCPAP to a TC which allowed him to be transferred out of the NICU for a brief time. Despite this progress, he again developed hypoventilation and acute respiratory distress resulting in admission to the Pediatric Intensive Care Unit for continuous ventilatory support. A need for long term mechanical ventilation soon became unavoidable. The goal was to transition him to the Pulmonetics LTV 1000 to allow him to be transferred home. Initial attempts failed as the patient's respiratory status worsened with frequent episodes of desaturation and bradycardia. He became unable to trigger the Dräger Baby Log 8000 Plus ventilator despite a neonatal flow sensor located at the patient wye with the sensitivity set at 1.0. His inability to generate even the minimal flow required to trigger the Dräger resulted in intolerance of any mode other than IMV, which was not well tolerated either. The weaning plan was revised and SIMV sprint trials were attempted. These attempts along with multiple other mode and setting changes failed, ending in successful placement on an Infant Star 500 with Star Synch and abdominal sensor to detect his efforts. He remained on the Infant Star for over a month, requiring multiple bronchoscopies with lasering of his trachea to remove recurrent granulation tissue. A final effort to transition to the LTV was successful after 3 months in the PICU and granulation tissue finally controlled. At this time he was able to trigger and maintain adequate ventilation with the following settings: PCV in the A/C mode, FIO2=.30, Rate=26BPM, PC=28, I-time=0.4seconds, Peep=10cmh20, sensitivity= 1LPM, rise time = profile 4. Measured settings were VT of 40-60cc, a VE of 1.2-2.5LPM, and a MAP of 15-17cmH20. Home Care planning and teaching were implemented prior to placement to home 15 days later. He has remained home for many months with the exception of scheduled overnight visits for routine Bronch/Laser surgeries. A June 2003 trip to Texas is planned for his evaluation for the Titanium Rib Project. If successful, this will serve to eliminate the flail chest physiology and correct an evolving scoliosis.
Discussion: In this case report, the Pulmonetics LTV 1000 demonstrates its ability to be a safe and effective ventilator for a patient less that 10kg with dismal respiratory physiology. This patient had the potential to remain in the ICU indefinitely. It is fortunate that he was able to be placed on a ventilator proven to be reliably used in the home setting.