The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

VOLUMETRIC DIFFUSIVE RESPIRATOR IN A PATIENT WITH CHEMICAL BURNS COMBINED WITH PRONE POSITIONING.

F. Khusid1, E. Fisher1, A. Sung1, S. Raoof 1, L. George1, A. Saleh1, V. Matatov1


INTRODUCTION:VDR delivers pneumatically powered, time cycled, pressure limited, flow-interrupted breaths and biphasic oscillation.
Prone positioning improves arterial oxygenation by decreasing pleural pressures in the dependent regions of the lung and decreasing interstitial fluid accumulation.

CASE SUMMARY: A 36 year old male patient presented to the Emergency Department with severe respiratory distress, fevers with rigors and central cyanosis. Three hours earlier, he had sustained a hydrochloric acid inhalation injury. He was placed on non-rebreathing mask,his SpO2 stabilized at 74%; he remained profoundly tachypneic
(RR-45/min), with bilateral expiratory rhonchi and was intubated.
PRVC-12, Vt – 550mL, FIO2 – 1.0, PEEP +5cm
Bronchoscopy revealed mucosal edema, necrosis and sloughing of airways at level of mid trachea, proximal right and left mainstream bronchi.

Patient was placed in the prone position bed with 20-degree rotation on either side.  Nearly 100mL of thick, purulent secretions were collected within next 24 hours.  It was difficult to oxygenate and ventilate the patient.

The ABG on PRVC-30, Vt-550, FIO2 – 1.0, PEEP +10cm in the prone position was; pH – 7.33, PaCO2 – 47, PaO2 – 74

He was placed on VDR in prone position on day 3 of hospitalization.
Pulsatile Flow Rate – 24cm, Oscillatory CPAP+10, I:E ratio1:1 Convective Pressure Rise +6cm, Pulse Frequency -585, Convective Rate -15, FIO2-1.0

ABG in 1 hour; pH-7.49 PaCO2 – 38 PaO2-198 O2Sat-100%

Within the first 8 hours of VDR and prone positioning, approximately 500mL of secretions were aspirated; FIO2 was titrated to 0.45 over the next 48 hours.  Patient was successfully extubated on day 7 of his admission.

DISCUSSION:
Despite placing the patient in the prone position and adding lateral rotation therapy, the airways secretions could not be adequately suctioned. Combination of VDR and Prone positioning showed significant improvement of oxygenation and removal of large amounts of secretions resulted in expedited weaning process.

Conclusion:
High flow pulses of inspiratory gas create a simultaneous expiratory airway counterflow that, in the presence of adequate humidification,create a sustained cephalad flow of sufficient velocity to mobilize secretions. In patients with copious secretions, airway injury and in a subset of patients with ARDS and leaky capillaries, the combination of VDR and Prone position may allow effective drainage of secretions and improve oxygenation.

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