The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

Safety and Feasibility of Inhaled Nitric Oxide Delivery with High-Frequency Jet Ventilation.

Hooshang Baghaee 1, Kabir M Abubakar 2 and Martin Keszler 2. 1Respiratory Care and 2Pediatric/Neonatalogy, Georgetown University, Washington, DC

Background: Inhaled Nitric Oxide (iNO) is commonly delivered via high frequency oscillatory ventilation (HFOV) in infants with hypoxic respiratory failure. Such infants often need to be transported to a center with extracorporeal membrane oxygenation (ECMO) capabilities. High frequency jet ventilation (HFJV, Bunnell Inc, Salt Lake City, UT) is the only form of HFV feasible in transport. HFJV offers advantages over HFOV in infants with airleak and is the preferred mode in many centers. Bench studies showed that iNO can be delivered reliably using HFJV and INOvent delivery system (Datex-Ohmeda, Madison, WI) but the combination has not been studied in infants, nor validated by the company. The product advisory warns against this combination because of concern that high pressure in the HFJV circuit may cause device failure.

Objective: To evaluate feasibility and safety of HFJV+INOvent during transport and NICU use.

Design/Methods: The INOvent injector module was adapted into the HFJV circuit so that iNO is delivered proximal to the humidifier. Nitric oxide (NO), nitrogen dioxide (NO2) and FiO2 were measured just proximal to the endotracheal tube. This circuit was used both in the NICU and on transport. We retrospectively examined ventilator variables, NO2 levels, technical problems and outcomes from the records of all infants who received iNO therapy+HFJV from 1999 to 2003.

Results: HFJV+iNO were used in 43 infants for a median of 88 h (range 2-346). Median gestational age was 39 wk (range 25-42). 7 infants were <34 wk. Median weight was 3460 g (range 690-5178). Six infants needed ECMO and 6 died (3 with pulmonary hypoplasia, 1 sepsis and 2 birth asphyxia). Eight patients had airleak, none developed new airleak while on HFJV+iNO.

  PIP (cmH2O) MAP (cmH2O) Circuit Pressure (PSI) NO conc. (PPM) NO2(PPM)
Maximum 50 21.4 9.8 29 0.9
Mean (range) 31 (18-50) 13 (4.6-21.4) 4.5 (1.8-9.8) 13.8 (1-29) 0.19 (0.1-0.9)

No device failure occurred during 3525 hours of use, including 28.8 hours during transport. HFJV circuit pressure (servo-pressure) ranged from 1.8-9.8 psi and was >5 psi for a total of 847 hours. No mechanical problems with the system were noted except battery failure either due to early power depletion or improper use of the power pack. There was no substantial discrepancy between set and measured NO concentrations.

Conclusions: The combination of HFJV+INOvent therapy is feasible during transport and NICU use and achieves outcomes comparable to other combinations of iNO and ventilatory support. No safety concerns were identified.

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