The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts


Matt McNally1, Robert Fitzgerald1, H. Worth Parker2; 1Respiratory Care, Dartmouth Hitchcock Medical Center, Lebanon, NH; 2Pulmonary Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH

Background: Cystic Fibrosis (CF) is the most common lethal genetic disorder of Caucasians. During a pulmonary exacerbation, airways resistance may increase due to excessive thick secretions and airway inflammation. Non-invasive ventilation (NIV) may be used to reduce increased work of breathing while Heliox may be used to overcome increased resistance of the airways. Case: A 38 year old male with advanced CF (genotype: G551D homozygote) and FEV1 of less than 20% of predicted presented with increased WOB, wheezing and changes in mental status despite high flow nasal cannula ( FiO2 0.6). A CXR revealed a new right lower lobe infiltrate. An ABG revealed a pH 7.23/ PaCO2 169/ PaO2 86/HCO3 68.4. NIV was started with an IPAP 15cmH2O and EPAP 8cm H2O. A follow up blood gas revealed 7.25/146/85. After 36 hours on NIV with the same settings the PaCO2 remained high (145mm) and the patient again presented with a decreased level of consciousness an increased WOB. Heliox was then added to power the ventilator with a total FiO2 0.3. A repeat blood gas revealed 7.38/94/60/58 and the patientÂ’s mental status improved along with his WOB. Treatment was continued and twelve hours later a repeat ABG revealed 7.41/73/72/48. The patient was weaned off the NIV and Heliox. Six days later worsened hypercapneia and symptoms returned and we were able to reproduce the same results using Heliox and NIV therapy. Discussion: Literature does exist to support the practice of using NIV in conjunction with Heliox therapy but none specifically in the case of an acute CF exacerbation. Henchey reports using Heliox alone to treat CF exacerbations and Stucki et al reports use of Heliox with non-invasive high frequency positive pressure ventilation. This case was able to show that these therapies can be used safely and effectively together to treat hypercapneia in an ill CF patient. It was also noted that the patient had a base line extremely productive cough that was suppressed during this exacerbation. Secretion clearance with the assistance of IPV, after Heliox and NIV, was back to baseline. In this particular case employing a combination of Heliox with NIV avoided intubation and enabled the patient to verbalize input into critical decisions at the end of life. Further studies in CF patients are indicated to validate these findings and clarify mechanisms of the observed improvement in gas exchange. Sponsored Research - None