The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

USE OF HIGH FLOW NASAL CANNULA ON A PEDIATRIC BURN PATIENT WITH INHALATION INJURY WHO FAILED EXTUBATION - CASE REPORT

B Cairns, MD, FACS, J Haithcock RRT, K Short RRT, RN, F Byerly, MD, North Carolina Jaycee Burn Center, University Of North Carolina Hospitals, Chapel Hill, NC.

Introduction: Inhalation injuries and associated adverse consequences both immediate and delayed have been reported extensively in the literature. Inhalation injuries in pediatric patients can be more complicated because respiratory distress is a consequence of airway edema, obstruction, or other residual effects, which can be directly related to the inhalation injury. We report a case of a twelve-month old female with 8% cutaneous burns and inhalation injuries who developed post extubation respiratory distress that was successfully managed on a noninvasive high flow nasal cannula device (Vapotherm™ 2000i).

Case:
On admission, the patient was intubated with a size 4 endotracheal tube and placed on a high frequency percussive ventilator (VDR-4), which assisted with secretion clearance and maintenance of oxygenation and ventilation. She remained on this mode of ventilation for 14 days and subsequently was switched to a SIMV mode on a conventional ventilator (Siemans Servo 300). After 3 days on SIMV she was extubated and placed on an aerosol facemask with 40% oxygen. Her initial heart rate was 146 and her respiratory rate was 40 breaths per minute. Within a short period of time her breath sounds became coarse with expiratory wheezes and her oxygen was increased to 50%. One dose of Albuterol (2.5 mg) and several doses of Racemic Epinephrine (5mg) were given via aerosol nebulization with no change in the patient’s condition. The patient’s heart rate increased to 175 beats per minute and her respiratory rate increased to 63 breaths per minute. Due to the patient’s increasing respiratory distress, plans were to re-intubate the patient for airway management. Instead, a decision was made to place the patient on the Vapotherm™ 2000i high flow nasal cannula. The initial flow rate was set at 15 lpm with 50% oxygen. Immediately after placing the patient on the high flow nasal cannula, the patient’s heart rate dropped to 144 beats per minute and her respiratory rate dropped to 33 breaths per minute. The patient became more comfortable with improved breath sounds, and she required less sedation. Over the course of the next three days oxygen was weaned to 30% and the nasal cannula flow was decreased to 10 lpm. The patient continued to improve and she was weaned to room air after 5 days and discharged shortly thereafter.

Discussion:
This experience indicates that the Vapotherm™ high flow nasal cannula device could be considered as an adjunctive treatment in some cases for post-extubation stridor and concurrent respiratory distress. We observed a marked improvement in patient comfort, a decrease in upper airway stridor, and an immediate decrease in heart rate and respiratory rate. We believe that we were able to forego reintubation of this pediatric patient by employing this new mode of therapy. More clinical controlled trials are needed to determine the full potential of this new technology.


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