The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

DELIVERY OF INSPIRED GAS IN THE DIFFERENTIAL DIAGNOSIS OF A BRONCHOPERICARDIAL FISTULA: A CASE STUDY

N. A. Fencl1, B. S. Marino1

A 25 year old male with d-Transposition of the Great Arteries, status post Senning procedure at 4 months of age, with atrial flutter and ventricular tachycardia, status post radiofrequency ablation, pacemaker and AICD placement, presented to clinic with congestive heart failure. The echocardiogram showed severe right ventricular dysfunction, mild left ventricular dysfunction, and moderate tricuspid regurgitation.

The patient required placement of a ventricular assist device in the systemic right ventricle during which he suffered a 12 minute VF arrest. He remained mechanically ventilated for 9 days post operatively. Three months later he received an orthotopic heart transplant which was complicated by significant bleeding, fungal sepsis, and multi organ system failure.

On post transplant day 27 the patient was taken urgently to the cardiac catheterization laboratory for placement of a pericardial catheter due to an expanding pneumopericardium of unknown etiology. The air leak was consistent with a bronchopericardial fistula. On post transplant day 30 the patient experienced increased work of breathing and desaturation into the 80s which he recovered from with a prolonged period of hand ventilation. A bedside bronchoscopy was performed which was unrevealing.

The following morning the patient was placed on a Servo 900C ventilator to deliver 1% Isoflurane. The POET® (Criticare Systems, Inc) anesthesia monitor was placed in line at the airway to monitor inspired and expired Isoflurane. Once this was verified, the POET® was removed from the patient’s airway, and placed on a stopcock attached to the pericardial catheter. After approximately 3 minutes, the POET® began to read expired Isoflurane from the pericardium. The clinical care team utilized this unconventional data to diagnose the bronchopericardial fistula.

A subsequent episode of tamponade due to the pnemopericardium resulted in a blood pressure of 70/30 and ABG of pH 7.18, CO2 75, PaO2 114, and BE -1. The patient’s status improved with the drawing off of air using the pericardial catheter and delivery of normal saline.

The patient’s pericardial drain has since been upsized to a 10 French Heimlich valve leading to some improvement of the pneumopericardium which is now small in size and no longer compromising the patient from a hemodynamic standpoint. He had a tracheostomy tube placed due to dependence on mechanical ventilation and remains in the Cardiac Intensive Care Unit.

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