The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts

HIGH FREQUENCY OSCILLATORY VENTILATION RESCUE REFRACTORY HYPOXEMIA IN A PATIENT WITH TRANSFUSION-RELATED ACUTE LUNG INJURY

Chin-Hua Huang1, Ching-Tzu Huang1, Han-Chung Hu2, Kuo-Chin Kao1,3, Chung-Chi Huang1,3, Meng-Jer Hsieh1,2; 1Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 2Thoracic Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; 3Respiratory Care, Chang Gung University, Taoyuan, Taiwan

Introduction : Transfusion-related acute lung injury (TRALI) is a rare but life-threatening complication of blood transfusions. Treatment of TRALI is mainly supportive, which includes mechanical ventilation. High frequency oscillatory ventilation (HFOV) is an alternative mechanical ventilation mode for adult patients with acute respiratory distress syndrome (ARDS). We report a case of TRALI who had refractory hypoxemia with conventional mechanical ventilation successfully treated by HFOV. Case Summary : A 32 year-old woman with diabetes mellitus, hypertension and chronic renal insufficiency was admitted due to hematemesis. Because of anemia (hemoglobin: 7.5 g/dL), two units of packed red blood cells (RBC) were transfused without adverse reaction. After six days, another 2 units of packed RBC was transfused to correct anemia (hemoglobin: 7.8 g/dL). Thirty minutes after completion of transfusion, she experienced sweating and severe respiratory distress with hypoxemia. Artery blood gas revealed pH 7.32, PaCO2 36 mm Hg and PaO2 65 mm Hg on simple mask 45% O2. The respiratory distress and hypoxemia did not respond to intravenous furosemide and she was intubated for mechanical ventilation. The chest X-ray revealed bilateral infiltration with acute pulmonary edema. Due to persistent refractory hypoxemia (PaO2 66 mm Hg) after PCV support with FiO2 1.0 and 18 cm H2O PEEP for 12 hours, the ventilator was changed to HFOV (3100B, Sensormedics, Yorba Linda, CA). The initial setting rate was 3.5 Hz. with a mean airway pressure set at 30 cm H2O. The oxygenation improved with HFOV. The PaO2/FiO2 ratio and alveolar-arterial oxygen difference before and after HFOV were shown in Figure 1. Mechanical ventilation was changed to conventional PCV after 2 days of HFOV. She was successfully extubated after 2 weeks of conventional mechanical ventilation. Discussions : Management of TRALI is largely supportive, with more then 70% of patients with TRALI requiring mechanical ventilation. HFOV is characterized by settings of high mean airway pressures with the rapid delivery of small tidal volumes of gas, which improves oxygenation and has been used as a rescue mode of ventilation in severe ARDS. The hypoxemia was effectively corrected by changing to HFOV. In TRALI patients with severe hypoxemia refractory to conventional mechanical ventilation, HFOV is a potential rescue modality to improve oxygenation. Sponsored Research-None Sponsored Research - None

The PaO2/FiO2 ratio and alveolar-arterial oxygen difference (D(A-a)O2) before and after the initiation of high-frequency oscillatory ventilation (HFOV).