The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

NON-INVASIVE VENTILATION WITH AIRWAY PRESSURE RELEASE VENTILATION (APRV) - A CASE REPORT.



Roberta L. Hales BS, RRT-NPS, RN, Howard Panitch MD, Vijay Srinivansan MD; The Children's Hospital of Philadelphia, Philadelphia, PA.

INTRODUCTION: Mucolipidoses Type II (ML-II), a progressive autosomal recessive lysomal lipid storage disease, causes abnormal deposits of substrates into tissue because of deficiencies of lysomal enzymes. Progressive accumulation of these substrates results in neurodegeneration, organomegaly, and skeletal abnormalities leading to early childhood death.

CASE: One-year-old male diagnosed with ML-II was admitted postoperatively to the Pediatric Intensive Care Unit (PICU) s/p tonsillectomy, adenoidectomy, uvolectomy and bilateral myringotomy tubes. On arrival to the PICU, the patient experienced multiple episodes of bradycardia and desaturations with no improvement from interventions. He was intubated and ventilated with APRV until day 7 when he was extubated. He did well for 6 hours, and then quickly deteriorated due to extrathoracic airway obstruction, requiring reintubation by flexible bronchoscopy. Ten days later, he was extubated to continuous non-invasive ventilation at FiO2 40%, S/T, Rate 10, IPAP 14 cmH2O, and EPAP 5 cmH2O. Overnight he had numerous episodes of significant desaturations (40-60's) and respiratory distress (respiratory rates 80's), requiring an increase in his ventilatory support. He was trialed on many non-invasive machines in an attempt to provide improved synchronization. After team discussion, the patient was placed on the Drager Evita XL in APRV with full-face mask ventilation. The initial settings were FiO2 85%, Pressure high (Phigh) 25 cmH2O, Pressure low (Plow) 5 cmH2O, Time high (Thigh) 2.8 seconds, and Time low (Tlow) 0.4 seconds. The arterial blood gas prior to initiation was pH 7.20, PaCO2 65 torr, PaO2 47 torr, on A/C Rate 30 bpm, IPAP 20 cmH2O, EPAP 10 cmH2O and 15 lpm of oxygen.

APRV settings and arterial blood gases were as follows:

  pH PaCO2 torr PaO2 torr HCO3 FiO2 % Phigh cmH2O Plow cmH2O Thigh Second Tlow Second Vtexh ml RR
1 hour 7.35 51 82 27 0.70 25 5 2.8 0.4 60 70
4 hours 7.34 52 81 28 0.60 25 5 2.8 0.4 68 66
6 hours 7.36 53 62 30 0.55 25 5 2.8 0.4 62 70
8 hours 7.38 50 60 29 0.55 25 5 2.8 0.4 60 70
10 hours 7.44 48 59 32 0.55 22 5 2.8 0.4 55 70
24 hours 7.46 48 56 33 0.50 20 5 2.8 0.4 45 45
36 hours 7.43 43 73 28 0.50 16 5 2.8 0.4 49 40

The patient transitioned to traditional biphasic ventilation with the Puritan Bennett Knight Star ® on day 4. Two days later, the patient converted to CPAP 12 cmH2O, FiO2 21% and began short trials off. The patient was discharged 10 days later on CPAP while asleep.

DISCUSSION: Many strategies are used to prevent intubation for impending respiratory failure. The utilization of non-invasive APRV may potentially reduce the need for an artificial airway. This non-invasive ventilation strategy resulted in a positive patient outcome.

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