2006 OPEN FORUM Abstracts
A CASE STUDY: APPLICATION OF CPAP TO THE RIGHT MAINSTEM BRONCHUS VIA A FOGARTY CATHETER
Cheryl L DeFalco, AS,
Roberta Hales, BS, RRT-NPS, RN, Mark Helfaer, MD, Todd Kilbaugh, MD; The Children's
Hospital of Philadelphia, Philadelphia, PA.
Introduction: A case report on the application of CPAP to the right mainstem bronchus (RMSB) via a Fogarty occlusive catheter. The patient required single lung ventilation and the use of an occlusive device to isolate the lungs. The patient was in respiratory failure secondary to pneumococcal pneumonia with bronchopulmonary fistula, plus bilateral pneumothoraces requiring multiple chest tubes. The patient was septic and displayed hypoxic insult.
Case Summary: A three-year-old child presented to the outside hospital (OSH) emergency room with a 6-day history of fever, vomiting and increasing respiratory distress. Original presentation included fever of 106°F, vomiting, respiratory distress, lethargy, and SpO2 of 80% on room air. The patient's condition rapidly deteriorated requiring emergent intubation with a 5.0-cuffed endotracheal tube and volume resuscitation. Initial ventilator settings: SIMV, Vt 120 ml, peep 10 cmH2O, peak pressures 26-30 cmH2O and a FIO2 50%. Initial chest CT revealed near complete consolidation of the right lung with cystic changes and a small pleural effusion. The patient's lung disease progressed predominately affecting the right lung with a follow-up chest CT revealing a small pleural effusion, pneumothorax, and uniform consolidation of the right lung. HFOV was initiated in attempt to diminish airleak trauma; however multiple pneumothoraces developed in the right lung requiring multiple pigtail catheters despite weaning the MAP. The persistent right lung air leaks led to the decision to selectively intubate the left mainstem bronchus (LMSB). The LMSB intubation was terminated after 7 days due to the potential of endobronchial injury. A Fogarty vascular catheter was placed in the RMSB as a balloon occlusive device. Repetitive attempts to recruit the right lung were unsuccessful. The patient remained on HFOV. The patient was transferred to The Children's Hospital of Philadelphia (CHOP) for a possible pneumonectomy due to suspected right lung necrosis. On arrival, the patient had a RMSB occlusion device and subsequently placed on HFOV and Nitric Oxide therapy. After 2 days, the occlusive device was attached to CPAP 10cmH2O. Prior to the initiation of CPAP, the right lung was completely consolidated. After application of CPAP, there was improved oxygenation and increased aeration noted to the right upper lobe each day.
|ABG prior to CPAP||7.49||47.7||80.6||36.1||11.7|
|1 hour post CPAP||7.48||50||114.6||36.6||11.7|
|24 hours post CPAP||7.44||51||138.8||34.2||9|
On the 4th day, CPAP was terminated and the balloon was deflated. The patient tolerated ventilation to both lungs and the catheter was removed. The patient was transitioned to conventional ventilation in Pressure Control: PIP 30 cmH2O, Peep 10 cmH2O and a Rate of 30. The patient was extubated one week later to Bilevel ventilation and began short trials to a nasal cannula 7 days later.
Discussion: Delivering of CPAP via the Fogarty catheter was shown to be successful in this case. Using the bronchial occlusive device to deliver CPAP via the RMSB enabled us to achieve the goal of effectively recruiting the lung independently. The Fogarty catheter provided us with a new strategy for managing smaller patients with large air leaks requiring independent lung ventilation. A drawback to using the Fogarty catheter is the small lumen, not allowing suctioning and/or pulmonary toilet to the isolated lung, potentially causing secretions, blood, and/or pus to obstruct the small lumen, thereby preventing successful application of CPAP.