High frequency oscillatory ventilation in acute chest syndrome: An effective secretion clearance approach
Introduction: The use of High Frequency Oscillatory Ventilation (HFOV) is a proven therapeutic modality for acute lung injury in the pediatric population. Acute Chest Syndrome (ACS) occurs in patients with sickle cell disease and is manifested by a rapid deterioration in respiratory status. Progressive hypoxia, diffuse radiographic infiltrates, dyspnea, cough, fever, and chest pain classically characterize ACS. The dominant pathophystologic problem is the development of severe sputum production and refractory mucous plugging. In these patients, HFOV may result in the development of dynamic hyperinflation ("air trapping"). We hypothesized that a secretion clearance approach using HFOV, aggressive suctioning and intermittent bronchoscopy would result in improved respiratory status. Methods: HFOV was utilized in three pediatric patients with ACS. The patients were 5, 6, and 9 years of age. The mean time on conventional mechanical ventilation (CMV) prior to HFOV was 31 ± 13 hours. Results: During CMV all patients developed refractory respiratory failure and severe secretions. The Oxygenation Index (OI) for these patients is listed in the table. The OI on CMV was obtained immediately prior to the change from CMV to HFOV. Oxygenation Index = (FiO2 X mean airway pressure) / (PaO2) Patient CMV OI HFOV OI-6hr HFOV OI-48hr #1 38 28 18 #2 32 17 15 #3 30 10 10 The mean time on HFOV was 134 ± 27 hours. Secretions were vigorously suctioned and bronchoscopy was performed three times while on HFOV in each patient. The mean number of hours until the patients were extubated after HFOV was 144 ± 96. All three patients survived without chronic lung disease. All were discharged to home without the need for supplemental oxygen or respiratory medications. Conclusions: In these three patients, OI dropped by an average of 15 within six hours of the institution of HFOV. Our approach for ACS with refractory mucous plugging, which includes the use of HFOV, aggressive suctioning and intermittent bronchoscopy, appears to be safe and effective.
Gentile, M; Pineda, J; Cheifetz, I; Meliones, J
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