2003 OPEN FORUM Abstracts
A NEW STRATEGY FOR ADULT BURN AND TRAUMA PATIENTS FAILING CONVENTIONAL MECHANICAL VENTILATION: HIGH FREQUENCY OSCILLATORY VENTILATION
Kim M. Whitford, RRT, NPS, Mark Hibbert, RRT, CPFT, Kevin N. Foster, MD, Daniel
M. Caruso, MD, Arizona Burn Center, Maricopa Integrated Health Systems, Phoenix,
Introduction: High Frequency Oscillatory Ventilation (HFOV) has been shown to optimize alveolar recruitment and augment oxygenation. To date, there have been numerous publications supporting the use of (HFOV) in neonates and pediatric patients with severe respiratory failure. In September 2001, the Federal Drug Administration approved the Sensomedics 3100B HFOV for use in adult patients in the United States. However, there are limited reports of its use in critically ill patients.
Methods: A retrospective review of burn and trauma patients who underwent treatment with HFOV between 3/2002 and 6/2003 was performed. Study variables included demographics, extent of injury, mode of ventilation prior to HFOV, serial blood gases, complications and long-term outcome.
RESULTS: Eleven patients who had severe adult respiratory distress syndrome were treated with HFOV. Ages ranged from 16 - 81 years. Five patients had burns with inhalation injury (11% - 85% TBSA burns). One patient presented with necrotizing fasciitis and pneumocystis pneumonia, and another had purpura fulminans involving 85% of his body. The four other patients injuries were diverse. A right lung avulsion after being hit by a car, a gunshot wound to the chest, a gastrointestinal bleed, and a liver laceration with abdominal injuries after being in a motor vehicle accident. Pressure regulated volume control ventilation was utilized prior to initiation of HFOV. Settings were a mean I:E ratio 1.5:1, tidal volume 650 ml, PEEP 12 cm H2O and FiO2 100%. Oxygenation improved significantly as shown by the PaO2/FiO2 ratio. Prior to initiation of HFOV, the mean PaO2/FiO2 was 58 mmHg and eight hours post HFOV the mean PaO2/FiO2 increased to 288 mmHg. HFOV was also utilized in the operating room, during procedures on three patients with an average operation time of three hours. The average length of HFOV was six days, and the mortality rate was 36%. Although four of the eleven patients expired, none died of respiratory failure. Two patients were taken off life support by their family, one died from toxic megacolon and another died of sepsis. The other patients were weaned to conventional ventilation and survived.
CONCLUSION: High frequency oscillatory ventilation increases bulk gas movement optimizing the alveolar surface, and is efficacious when conventional ventilation fails. Moreover, HFOV can be successfully utilized in the critical care unit or the operating theater. Early initiation of HFOV in burn and trauma patients is not a predetermination of survival, but preliminary results show that HFOV should not be limited to a salvage therapy.