2012 OPEN FORUM Abstracts
SUCCESSFUL USE OF A PROLONGED INSPIRATORY TIME ON THE BUNNELL LIFE PULSE HFJV IN TREATING PNEUMONIA REFRACTORY TO CONVENTIONAL AND HFOV VENTILATION IN A NICU PATIENT.
Kimberly A. Barner, Lorraine Dickey; Resp Care, Lehigh Valley Health Network, Allentown, PA
Introduction: A 28 week infant on high flow nasal cannula, who developed an acute feeding intolerance on DOL 55. Intravenous access was difficult and Broviac placement was required. She was intubated for the surgical procedure and returned to the NICU on conventional ventilatory support; PSIMV rate 40, target volume 4-6 ml/kg (inspiratory pressure 22), PEEP 6. Post-operatively, attempts to wean were unsuccessful, requiring increasing FiO2 to maintain saturations > 88%. Within 24 hours she developed a right upper lobe consolidation consistent with pneumonia and required increased ventilatory support. She was then changed to HFOV, and over the next week showed no significant improvement despite IV and inhaled antibiotic therapy,and rigorous pulmonary toilet including chest physiotherapy and frequent suctioning. Intervention: On D#68 the decision was made to change ventilation strategy, and she was changed to the Bunnell Life Pulse HFJV. Consideration was given to the difference in time constants of the consolidated region, the need to recruit this area, and a desire to not increase PAW by increasing PEEP any further. A trial of increasing the Ti to 0.03s was undertaken. Results: Improvement in CBG results were evident after 30 minutes on the HFJV, and CXR showed slightly improved aeration in the RUL after 3 hours. Settings were weaned cautiously while intentionally maintaining the amplitude (Delta P of 30) with improvement in PCO2 and decreasing FiO2 requirement. On D#75, patient demonstrated clinical improvement with decreased ventilatory support, improved CBG results, and improvement in RUL recruitment on CXR. At this time she was transitioned to CMV with FiO2 requirements consistently below 35%. Conclusions: Changing to the Bunnell Life Pulse HFJV proved to be an effective strategy for improvement in both the removal of secretions and lung recruitment. Increasing the inspiratory time to 0.03s provided the compensatory yet necessary contribution to the PAW while allowing the PEEP to be weaned from 15 to 8 over a 7 day period. This change in strategy combined with intentionally weaning PIP and PEEP together to maintain constant amplitude (Delta P = 30) in the initial phases also resulted in ventilation parameters being weaned slowly but significantly. The consolidated lung, previously refractory to interventions with convention ventilation, HFOV, and aggressive pulmonary hygiene therapies, was successfully recruited. Sponsored Research - None