2004 OPEN FORUM Abstracts
THE UTILIZATION OF HIGH DOSE PROVENTIL VIA HIGH FREQUENCY PERCUSSIVE VENTILATION IN ACUTE LUNG INJURY
Miller, RRT-NPS, Mark Cipolle, MD, Gordon Coleman, RRT,
Larry Mann, RRT, Kenton Clay, RRT, Rick Wieand, RRT,
Linda Cornman, RRT-NPS, Kristin Sedler, RRT, James Gates, RRT. Lehigh Valley Hospital, Allentown, PA 18105.
Introduction: The administration of a beta-agonist during mechanical ventilation is well researched and documented.
Under the best circumstances,
distribution of an aerosolized drug can be only twenty percent in the mechanically ventilated patient. Aerosol delivery during High Frequency Percussive Ventilation (HFPV) has been minimally researched. We present a case study examining this question.
Case study: A fifty-three year old male with a history of chronic pneumonia and bronchitis had a left lower lobe resection. Twelve hours post-operatively the patient developed acute pulmonary edema after the onset of stridor. He was placed on volume targeted ventilation, then quickly changed to ARDSnet ventilatory strategy secondary to plateau pressure (plt) above 30cm/h2O. Target volume was reduced to 4cc/kg secondary to plt greater than 30cm/h2O. Proventil 2.5mg was delivered Q4hrs.via nebulizer and oxygenation was maintained on 70% oxygen and 14 cm/H2O PEEP. After thirty-six hours on ARDSnet ventilatory strategy the PaCO2>100 torr and the pH<7.10. The PaO2/FIO2 ratio was<200 torr. The ventilatory strategy was changed to HFPV via the VDR-4. Acid-base balance and oxygenation status remained marginal. X-ray revealed bilateral white-out with good lung expansion without evidence of hyper-inflation. On the third day on HFPV the patient developed a pneumothorax and a chest tube was inserted. PH and oxygenation status remained marginal over the next several days. On ventilator day 12 the PaCO2>100 torr and PH<7.15 despite increasing PIP/PEEP parameters to 70/20 cm/h20. Bedside bronchoscopy and tracheostomy were performed without any sufficient improvement in gas exchange. ETCO2 capnography demonstrated evidence of airway obstruction. Chest expansion was minimal. Proventil dose was increased to 10mg and delivered via updraft nebulizer. A drop in ETCO2 was noted and chest rise increased. Additional Proventil 10mg treatments reduced PaCO2 to acceptable levels were administered q2-4hrs in-line with the VDR-4. Over the course of the next few days PIP/PEEP parameters were reduced and oxygenation and ventilatory status remained stable. The patient was returned to pressure target ventilation via the Evita 4.
Conclusion: Aerosol delivery via High Frequency Percussive Ventilation has not been completely researched. Based on the high flow through the phasitron on the VDR-4 and the entrainment of bias flow, less aerosolized medication may reach the airways. Based on this principle and the results of our case presentation possibly a higher dosage of medication should be considered. Future research in this area should be conducted.