2004 OPEN FORUM Abstracts
THE UTILIZATION OF HIGH DOSE PROVENTIL VIA HIGH FREQUENCY PERCUSSIVE VENTILATION IN ACUTE LUNG INJURY
Kenneth
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.