2012 OPEN FORUM Abstracts
A CASE STUDY: APPLICATION OF HIGH FREQUENCY PERCUSSIVE VENTILATION (HFPV) DURING BI-CAVAL DUAL LUMEN VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION (VV-ECMO).
Cheryl Dominick1, Nicole Rizkalla2, Leah Rhodes-Eve1, Rita Giordano1, Maureen Ginda1, James Connelly3, Todd Kilbaugh2; 1Respiratory Care, Childrens Hospital of Philadelphia, Philadelphia, PA; 2Anesthesiology and Critical Care Medicine, Childrens Hospital of Philadelphia, Philadelphia, PA; 3ECMO, Childrens Hospital of Philadelphia, Philadelphia, PA
Introduction:Application of HFPV for lung protective recruitment in a patient supported with VV-ECMO for severe air leak secondary to tracheal injury.Case Summary: A 7 y/o male presented with status epilepticus and associated vomiting and was treated with diazepam. Resulting apnea required intubation in the field. Dislodgement necessitated reintubation in the emergency room. CXR revealed severe pneumomediastinum, and extensive infiltrates. Bronchoscopy and chest CT demonstrated a 2 cm tracheal tear. Air leak worsened, with OI increasing to 50. The patient was non-operatively managed with bi-caval dual lumen VV-ECMO, and placed on rest ventilator settings. On day 6 of VV-ECMO, delivered pressures were increased over 5 days to PIP 20 and PEEP 10 without radiographic improvement or detectable exhaled tidal volume. Recruitment maneuvers, use of APRV with mean airway pressure (MAP) of 22, and bronchoscopy did not result in lung opening. Daily bronchoscopy was performed for secretion clearance and lung recruitment. The patient was then converted to HFPV with an oscillatory PEEP 8, demand PEEP 2, pulsatile flow (PIP) 30, convective rate 20, percussive rate 550, and MAP 18 to 19 on ECMO day 14. After 1 hour of HFPV, there was brisk secretion clearance and improved right lung aeration. Within 24 hours of HFPV, CXR displayed bilateral lung expansion. Decannulation occurred ECMO day 16, HFPV was continued for 4 days post-decannulation, and the patient was discharged from the ICU on day 45.Discussion:HFPV is a flow regulated, time-cycled pressure mode of ventilation that allows for airway clearance, while efficiently exchanging gas via high frequency, sub-tidal volume breaths at lower delivered transpulmonary pressures. In anticipation of decannulation, several methods of lung recruitment are employed in patients with ARDS on ECMO following management with rest settings: high PEEP, open lung ventilation with APRV/HFOV, and serial bronchoscopy. These strategies are used with variable success, and may expose injured lung to trauma. HFPV combines the benefits of high frequency ventilation and conventional bulk flow gas exchange, resulting in effective secretion mobilization and alveolar recruitment while limiting barotrauma. We report the successful use of HFPV as a lung-recruitment technique in a patient with resolving air leak and ARDS, managed with bi-caval dual lumen VV-ECMO. Sponsored Research - None A:CXR after PICU admission shows pneumomediastinum & bilateral infiltrates.