2004 OPEN FORUM Abstracts
High Frequency Percussive Ventilation in a Pediatric Patient with Hydrocarbon Aspiration –CASE REPORT
T Mabe, RRT,
T Honeycutt, MD, B Cairns, MD FACS, K Kocis, MD, MS, K Short, RRT,
RN, Departments of Pediatrics and Surgery, University of North
Carolina Hospitals, Chapel Hill, N.C.
Introduction: Mineral oil is a common remedy to treat chronic constipation in the pediatric population. Ingestion of mineral oil by infants and children may not evoke a protective cough reflex, and ultimately aspiration can occur. Aspiration of hydrocarbon (mineral oil) can result in severe pneumonitis and in cases of chronic aspiration it can lead to lipoid pneumonia over time. We describe the ventilator management of a previously healthy eleven-month-old male with severe aspiration pneumonitis from mineral oil using a high frequency percussive ventilator (HFPV), after other modes of mechanical ventilation failed to improve the status of the child. The HFPV delivers sub-tidal volumes superimposed on to conventional type breaths. Short expiratory times can be set to allow for auto-peep to occur and exhalation is active. The sub-tidal volumes or percussions inherent in the HFPV allow for effective mobilization of secretions.
Case: The patient was transferred to our Pediatric Intensive Care Unit from a nearby hospital, intubated and ventilated for management of his respiratory failure. He was initially placed on a conventional ventilator in a pressure regulated volume control mode for approximately one hour but needed higher than normal pressures to maintain adequate ventilation. A decision was made to switch the patient to a pressure control/pressure support mode (PCV/PSV) on a Servo-i ventilator with PSV 10, PCV 20-24, PEEP 8, and FIO2 50-80%. ABG’s on these settings were pH 7.16-7.21, PCO2 46-62, and PaO2 60-120. At the end of the third day on PCV/PSV, a decision was made to attempt airway pressure release ventilation (APRV) due to worsening of the patient’s oxygenation. During an hour trial of APRV, oxygen saturation levels deteriorated to low levels and a decision was made to place the patient on the 3100A high frequency oscillator (Sensormedics). The high frequency oscillator (HFO) settings were Hz 8, amplitude 40-48, MAP 25-28, and FIO2 50-100%. The patient remained on this mode of ventilation for 6 days with ABG’s pH 7.38 (± 5), PCO2 50-60, and PaO2 57-100. On the sixth day of HFO, the chest x-ray showed a worsening of his pneumonia and the patient started to deteriorate with oxygen saturations in the low 80’s. A decision was made to try the HFPV (VDR-4) in an attempt to mobilize secretions and any residual mineral oil. Initial settings on the HFPV were PIP 26, PEEP 8, phase rate 20, percussive rate 600, inspiratory time 2.5 seconds, and FIO2 100%. Immediately after initiating the HFPV and for four hours following, large amounts of secretions including a thick oily substance were suctioned from the airways. Within 12-24 hours oxygenation improved dramatically and FIO2 was weaned to 35%. During the next 12 hours the patient was weaned off the HFPV onto a conventional ventilator with a volume support mode and he was subsequently extubated 48 hours after initiating HFPV.
Discussion:The beneficial use of HFPV in inhalation injuries to facilitate removal of carbonaceous secretions has been well documented. The benefits of the intermittent intrapulmonary percussive machine have been well documented in mobilizing secretions in cystic fibrosis patients. We observed with this case that HFPV, as an alternative mode of ventilation successfully mobilized secretions that were otherwise unobtainable and we believe led to the swift recovery of this child. HFPV should be given consideration as a mode of ventilation when mobilization of secretions is an issue. Further study of the possible expanded use of the HFPV in certain clinical situations seems to be warranted.