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Amoretti CF, Hamerchlak N, Faria LS, Haddad LB, Troster EJ
CASE REPORT
High frequency ventilation in acute respiratory distress syndrome: a case report Ventilação de alta freqüência na síndrome de desconforto respiratório agudo: um relato de caso Carolina Friedrich Amoretti1, Nelson Hamerschlak2, Lucília Santana Faria3, Luciana Branco Haddad4, Eduardo Juan Troster5
ABSTRACT Acute Respiratory Distress Syndrome is a common entity that affects patients with serious conditions and has a high mortality rate. It was published ten years ago that pulmonary protective ventilation, with low tidal volumes and high respiratory frequencies, would have a positive impact on the mortality rates of patients with acute respiratory distress syndrome. Hence, the interest in high frequency ventilation has risen since it is as a safe and effective way to provide protective ventilation. This is a case report of a patient with congenital acute lymphoid leukemia, who progressed with severe sepsis and acute respiratory distress syndrome and benefited from high frequency ventilation. Keywords: Acute respiratory distress syndrome; High frequency ventilation, Protective pulmonary ventilation; Pulmonary shock; Shock
RESUMO A síndrome do desconforto respiratório agudo é uma condição pulmonar que complica uma série de doenças graves e carrega consigo um alto índice de mortalidade. Há cerca de uma década foi descrito que o uso de ventilação mecânica protetora, com volumes correntes baixos, teria um impacto positivo na mortalidade destes pacientes. Assim, renovou-se o interesse pelo uso da ventilação de alta freqüência como um método seguro e eficaz para atingir os objetivos de ventilação protetora. Este trabalho é um relato de caso de uma paciente com leucemia linfóide aguda congênita que evoluiu com quadro de sepse grave e desconforto respiratório agudo, obtendo muito benefício da ventilação de alta freqüência. Descritores: Ventilação de alta freqüência; Síndrome do desconforto respiratório agudo (SARA); Ventilação mecânica protetora; Pulmão de choque; Choque
INTRODUCTION Leukemia in infancy is a rare disease with a poor prognosis. The first line treatment is chemotherapy (CT) considering there is an increased risk of infections (1). Acute respiratory distress syndrome (ARDS) is a high mortality condition (achieving 62% in the pediatric population) (2) that worsens severe infection leading to sepsis. The scientific community has recently been introduced to new mechanical ventilation techniques that are adjusted to management of ARDS. High frequency ventilation (HFV) is one of these techniques and there are studies demonstrating its safety and efficacy. We report a case to illustrate the action of HFV in a lung with ARDS. CASE REPORT A fullterm female infant, birth weight of 3980 grams was diagnosed as having acute lymphoid leukemia at the age of 2 months and 20 days. She presented hepatosplenomegaly, petechiae and vomiting, an 11q23 translocation and invasion of the central nervous system at diagnosis. At the age of three months, after a chemotherapy cycle (BFM 95, high-risk) she presented pancytopenia and fever and progressed to severe sepsis. Despite the use of broad-spectrum antibiotics covering Pneumocystis carini and cytomegalovirus (with later positive antigenemia), the patient progressed with decreased room-air saturation and the chest X-ray revealed interstitial infiltrate. Ventilatory support with
Study carried out at Hospital Israelita Albert Einstein - HIAE, São Paulo (SP), Brazil. 1
Resident in Pediatrics - Pediatric Intensive Care Unit, Hospital de Clínica de Porto Alegre- RS. Elective trainee at the Pediatric ICU of the Hospital Israelita Albert Einstein – SP., Hospital de Clínica de Porto Alegre - RS and Hospital Israelita Albert Einstein - SP, Porto Alegre (RS), Brazil.
2
Hematologist of the Pediatric Specialty Clinic and of the Oncology Program at the Hospital Israelita Albert Einstein (HIAE). Ph.D. from the Universidade de São Paulo - USP - São Paulo (SP), Brazil.
3
Coordinator of the Pediatric ICU of Hospital Sírio-Libanês; Physican of the Pediatric ICU of Hospital Israelita Albert Einstein (HIAE); Physician of the Pediatric ICU of HC da FMUSP; Hospital Sírio-Libanês, Hospital Israelita Albert Einstein, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP), Brazil.
4
Physical therapist of the Pediatric ICU of the Hospital Israelita Albert Einstein (HIAE) - São Paulo (SP), Brazil.
5
Coordinator of the Pediatric ICU of the Hospital Israelita Albert Einstein (HIAE); Coordinator of the Pediatric ICU of the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, São Paulo (SP), Brazil. Corresponding author: Carolina Friedrich Amoretti – R. 17 de Junho, 926/904 - Menino Deus - CEP 00000-000 – Porto Alegre (RS), Brasil - Tel.: (51) 2101 8399 - e-mail:
[email protected] Received on April 13, 2005 - Accepted on August 17, 2005
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DISCUSSION According to the definition of the American-European Consensus Conference on ARDS, this condition is defined by acute onset, bilateral infiltrate on chest Xray, pulmonary artery occlusion pressure =18 mmHg (with no clinical evidence of right atrial hypertension) and PaO2/FiO2 ratio = 200(3). These features and a ratio = 300 characterize an acute lung injury (ALI). A recent study discussed if the pulmonary or extrapulmonary origin of ARDS would interfere in the management and prognosis of patients(4). In the case described above, it is an infant with febrile neutropenia, generalized infection and on chemotherapeutical agents. Therefore, the origin of ARDS seems to be predominantly extrapulmonary with a better prognosis. Among the causes of acute respiratory failure, ALI and ARDS are the most often associated to high morbidity and mortality rates (5). Mortality of these conditions accounts for 35-60% in adults and the only intervention that could reduce it in these patients is lung protective mechanical ventilation (PMV), with low tidal volumes(2-6). However, these data are not welldefined in children. Data published by the Pediatric Acute Lung Injury and Sepsis Investigator Network (PALISI) regarding nine North-American pediatric ICUs showed an ARDS incidence of 7.6%. The etiology and epidemiology of ALI and ARDS are different among adults and children, thus their management and
CPAP 12 was initiated on the night of day 1. On the dawn of day 2 she had to be intubated due to worse breathing conditions. At first, ventilation was set to controlled pressure (progression in figure 1), but the infant presented a significant CO2 retention and an inappropriate PaO2/FiO2 ratio (Table 1). The ventilatory mode was adjusted to pressure regulated volume control (PRVC) and PaCO2 improved; however the infant required an inspiratory pressure up to 45 cm H2O to achieve a tidal volume of up to 8.5 ml/kg. HFV was indicated and the radiological image improved. On the night of day 6, the patient was put in synchronized intermittent mechanical ventilation (SIMV) with low parameters and good tolerance.
Figure 1. Arterial gases vs. ventilatory mode Table 1. PaO2/FiO2 vs. ventilatory mode Day 2 Tire 1:30 pH 7.14 pC 02 59.8 p02 86.2 HC 03 19.6 BE Saturation (%) 93.3 Ventilatony PC Type Inspiration 24 Pressure PEEP 10 RF (mpm) 25 Fi02 (%) 85 Tidal Volume (ml/kg) Amplitude MAP RF (Hz) PaO2/FiO2 101
2 8:00 7.15 55.1 68.4 10 -13 89.9 PC
2 11:00 6.79 134 69.1 20.1 -20 83 PC
2 14:45 6.95 85.3 92.3 17.9 -15.3 95 PRV
2 17:20 7.19 52.2 70.7 19.5 -8.1 95.4 PRV
30
35
–
–
21
10 30 75
12 35 100
10 40 100 8.5
10 60 100 7.2
8 22 25
386
91
69
92.3
70.7
3 1:10 7.08 74.1 112 21.5 -8.9 98 HFV
3 3:55 7.23 54 91.8 21.7 -5.5 97 HFV
3 6:30 7.31 44 112 21.5 -3.9 85 HFV
3 17:00 7.35 36.9 141 20.2 -4.3 99 HFV
4 6:00 7.27 54.8 124 24.7 -2.4 98 HFV
5 6:00 7.44 33.4 74.8 22.8 -0.3 96 HFV
6 12:00 736 35 117 19.5 -4.7 98 PC
65
45
40
30
25
25
9 30 35
32 28 8 172
44 28 7 204
44 28 7 280
44 25 7 470
38 24 7 496
38 24 7 299
334
7 8:30 7.39 28.1 96.7 17 -6.3 97 SIMV
BE = base excess PC = pressure controlled PRVC = pressure regulated, volume controlled MAP = mean airway pressure RF = respiratory frequency PEEP = positive end expiratory pressure HFV = hight frequency ventilation SIMV = synchronous intermittent mandatory ventilation
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prognosis are also diverse(7). A recent study with 328 children with ALI/ARDS demonstrated a mortality of 22%(6), and another investigation carried out before and only with children suffering from ARDS reported a mortality of 62%, with a confidence interval of 4874%(2). As compared with adults, mortality in children is related to severity of lung injury and is not much influenced by co-morbidities. Hence, the PaO2/FiO2 ratio may be used as a predictive factor of severity and outcome in Pediatrics(4). From 1998 to 2000, several studies assessed the effect of PMV on mortality of ARDS. In 2000, a multicenter, randomized study with adults demonstrated a significant decrease in mortality by using low tidal volumes(8). The results of these investigations and of others carried out later generated new interest in the use of HFV in these patients. HFV allows adequate ventilation with low tidal volumes, ranging from 1 to 3 ml/kg, with increased alveolar recruitment and barotrauma prevention(7,9). A study with 328 children mentioned above identified the following independent factors for mortality: PaO 2/FiO 2 ratio, presence of dysfunction in other organs (apart from lungs) and central nervous system dysfunction(6). An analysis of current data on PMV concluded that management should depend on the individual response(10). The studies on HFV reviewed in this report demonstrated it is a safe and effective ventilation mode, and has been increasingly used in ALI/ARDS patients.
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However there are still some doubts about the length of treatment, profile of patients who would get more benefits and the existence of HFV protocols, among others, that must be explained by further studies.
REFERENCES 1. Laughton SJ, Ashton LJ, Kwan E, Noris MD, Harber M, Marshall GM. Early responses to chemotherapy of normal and malignant hematologic cells are prognosis in children with acute lymphoblastic leukemia. J Clin Oncol. 2005;23(10):2264-71. 2. Davis SL, Furman DP, Costarino AT Jr. Adult respiratory distress syndrome in children: associated disease, clinical course and predictors of death. J Pediatr. 1993;123(1):35-45. 3. Ware LB, Matthay MA. The Acute Respiratory Distress Syndrome. N Engl J Med. 2000;342(18):1334-49. 4. Rocco PRM, Zin WA . Pulmonary and extrapulmonary acute respiratory distress syndrome: are they different? Curr Opin Crit Care. 2005;11(1):10-7. 5. Ware LB. Prognostic determinants of acute respiratory distress syndrome in adults: Impact on clinical trial design. Crit Care Med. 2005;33(3):S217- 22. 6. Flori HR, Glidden DV, Rutherford GW, Matthay MA. Pediatric acute lung injury: prospective evaluation of risk factor associated with mortality. Am J Respir Crit Care Med. 2005;171(9):995-1001. 7. Mehta NM, Arnold JH. Mechanical ventilation in children with acute respiratory failure. Curr Opin Crit Care. 2004;10(1):7-12. 8. Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson T, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;18(342):1301-8. 9. Marraro GA. Innovative practices of ventilatory support with pediatric patients. Pediatr Crit Care Med. 2003;4(1):8-20. 10. Marini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a consensus of two. Crit Care Med. 2004;32(1):250-5.
