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.