Ventilation of a 7 Year Old
Victim of Crush Injury to the Upper Chest with
Tracheal Bronchial Tears Using High Frequency Jet Ventilation
Joseph A. La Spada, Julie A. Long, Jorge Del Toro, and Jackson Wong, Division
of Pediatrics and Division of Pediatric Surgery, Broward General Medical
Center, Fort Lauderdale, FL 33316.
A previously healthy 7 year old girl experienced a severe crush injury
to the upper chest area resulting in severe bilateral lung contusions and
pneumothoraces along with extensive tearing of the membranous portion of
the trachea involving both the left and right main stem bronchus. The patient
required complicated and prolonged surgical repair of the airway.
Ventilation of this patient proved extremely difficult post operatively
due to the patient's extremely poor lung compliance and the need to keep
her airway pressures at a minimum. Initial attempts to ventilate this patient
included high frequency oscillation, conventional ventilation, and high
frequency positive pressure ventilation. These attempts were unsuccessful
with inability to decrease the patient's PaCO2
to less than 170 mm Hg or increase the patient's arterial pH to greater
than 6.80.
Although the patient weighed nearly 25 kg, she was successfully ventilated
using high-frequency jet ventilation (HFJV) via the Bunnell Life Pulse™
ventilator and a LifePort™ endotracheal tube adapter for use with the
patient's standard 5.5mm endotracheal tube. After one hour and 15 minutes
of HFJV, arterial pH increased to 7.21 with a significant decrease of PaCO2
to 72 mmHg. After two hours and 10 minutes of HFJV, arterial pH increased
to 7.52 with a PaCO2 of 26 mmHg.
The patient's overall respiratory status continued to improve following
this allowing extubation 11 days after admission and discharge home 14 days
after admission. Follow up bronchoscopy performed one week after surgery
showed healing of the tracheobronchial tear without granuloma formation
or presence of tracheitis.
HFJV has been used for years with success in infants and adults for various
conditions where conventional ventilation has failed including bronchopleural
fistulas, severe ARDS and traumatic large airway disruption. Despite this
fact, HFJV has traditionally not been considered for use in mid-range pediatric
patients due to limitations of the available high-frequency jet ventilators
and associated accessories in respect to the patient's size and weight.
In this case the high-frequency jet ventilator used, although particularly
indicated for use with infants, proved flexible enough for use in an older
child with use of an adapter. Further studies should be considered to expand
the age range for use of HFJV in children.
Presented at the 1998 Snowbird Conference on High Frequency
Ventilation.
