2005 OPEN FORUM Abstracts
HFJV AND HIGH PEEP STRATEGY IN THE MANAGEMENT OF SEVERE HYPOXEMIA AND HYPERCARBIA: A CASE REPORT
SD King RRT, LB Simpson RRT, RB Campbell, RRT, JD Davies, RRT, DT Tanaka, MD Duke Children's Hospital Durham, NC.
INTRODUCTION: High Frequency Jet Ventilator (HFJV) (Life Pulse; Bunnell Inc., Salt Lake City, UT) is used for ventilatory support for neonatal and pediatric patients with Respiratory Distress Syndrome (RDS). HFJV uses small, high velocity breaths and fast rates along with passive exhalation to achieve low pressure swings in the lung. Due to its breath delivery mechanics, HFJV is used as a mode of ventilation when conventional ventilators have failed. In this case report we describe the ventilator management of a 28 week premature infant with acute hypoxemia and hypercarbia secondary to pulmonary hemorrhage.
CASE SUMMARY: A 620 gram, 28 week gestational age male neonate with RDS developed acute pulmonary hemorrhage resulting in acute deterioration in blood gases while receiving HFJV. CBG results were pH 7.10, PCO2 67, PO2 27, HCO3 20 on the following settings: PEEP 5 cmH2O, Mean Airway Pressure (MAP) 13.1 cmH2O, PIP 20 cmH2O, RR 420. During manual ventilation frank red blood was noted in endotracheal tube (ETT). After stabilization of oxygen saturation (SpO2), High Frequency Oscillatory Ventilator (HFOV) was instituted with a MAP 15 and Hz 15. However, the patient continued to present with frank red blood in ETT, display hemodynamic instability, and the SpO2 fell below 70%. The patient was removed from HFOV. Once again, manual ventilation resulted in raising the SpO2 to above 90%. A jet injector placed inline revealed that a MAP of 25 cmH2O and PIP of 50 cmH2O was being provided by manual ventilation. HFJV was reinstituted with PIP (42 cmH2O) and PEEP (20 cmH2O) set to duplicate the MAP provided during manual ventilation. The new settings achieved a MAP of 25.3 cmH2O and SpO2 increased to 96%. A chest radiograph revealed bilateral lung expansion with no pneumothorax. Repeat CBG results were pH 7.47, PCO2 42, PO2 51. Weaning of PIP, PEEP and FiO2 began after a stabilization period of approximately one hour.
DISCUSSION: The use of high PEEP in refractory hypoxemia has been well documented. This case was unique because HFJV with high PEEP/high MAP was utilized to treat severe hypoxemia and hypercarbia secondary to pulmonary hemorrhage in the absence of a pneumothorax. Using HFJV in conjunction with a high PEEP/high MAP strategy appeared to reverse and stabilize CBG values in this scenario of RDS with accompanying pulmonary hemorrhage.