Abstract
Purpose
To present a case of severe hypercapnic respiratory failure in an adult burn patient and to describe our clinical problem solving approach during support with an unconventional mode of mechanical ventilation.
Clinical features
A 19-yr-old male with smoke inhalation and flame burns to 50% total body surface area was admitted to the Ross Tilley Burn Centre. High frequency oscillatory ventilation (HFOV) was initiated on day three for treatment of severe hypoxemia. By day four, the patient met consensus criteria for acute respiratory distress syndrome. On day nine, alveolar ventilation was severely compromised and was characterized by hypercapnea (PaC02 136 mmHg) and acidosis (pH 7.10). Attempts to improve CO2 elimination by a decrease in the HFOV oscillatory frequency and an increase in the amplitude pressure failed. An intentional orotracheal tube cuff leak was also ineffective. A 6.0-mm nasotracheal tube was inserted into the supraglottic hypopharynx to palliate presumed expiratory upper airway obstruction. After nasotracheal tube placement, an intentional cuff leak of the orotracheal tube improved ventilation (PaCO2 81 mmHg) and relieved the acidosis (pH 7.30). The improvement in ventilation (with normal oxygen saturation) was sustained until the patient’s death from multiple organ dysfunction four days later.
Conclusion
During HFOV in burn patients, postresuscitation edema of the supraglottic upper airway may cause expiratory upper airway obstruction. The insertion of a nasotracheal tube, combined with an intentional orotracheal cuff leak may improve alveolar ventilation during HFOV in such patients.
Résumé
Objectif
Présenter un cas de défaillance respiratoire hypercapnique sévère chez un grand brûlé adulte et décrire la démarche clinique adoptée pendant l’établissement d’une ventilation mécanique non traditionnelle.
Éléments cliniques
Un homme de 19 ans exposé à des flammes et à l’inhalation de fumée a subi des brûlures sur 50 % de la surface corporelle et a été pris en charge au Ross Tilley Burn Centre. La ventilation oscillatoire à haute fréquence (VOHF) a été instaurée au troisième jour postopératoire pour traiter une hypoxémie sévère. Au quatrième jour, la condition du patient présentait tous les critères d’un syndrome de détresse respiratoire. Le neuvième jour, la ventilation alvéolaire était sérieusement compromise et caractérisée par de l’hypercapnie (PaC02 136 mmHg) et de l’acidose (pH 7,10). Les tentatives pour améliorer l’élimination du CO2 en diminuant la fréquence oscillatoire de la VOHF et en augmentant la pression d’amplitude ont échoué. Une fuite provoquée volontairement dans le ballonnet du tube orotrachéal a été aussi inefficace. Un tube nasotrachéal de 6,0 mm a été inséré dans l’hypopharynx supraglottique pour pallier l’obstruction présumée des voies respiratoires supérieures. Après la mise en place du tube nasotrachéal, une fuite intentionnelle du ballonnet du tube orotrachéal a amélioré la ventilation (PaCO2 81 mmHg) et fait disparaître l’acidose (pH 7,30). L’amélioration de la ventilation (avec une saturation normale en oxygène) a été maintenue jusqu’au décès du patient, quelques jours plus tard à la suite d’une défaillance multiviscérale.
Conclusion
Pendant la VOHF chez des grands brûlés, l’œdème des voies respiratoires supraglottiques en période postranimation peut causer une obstruction des voies respiratoires supérieures. L’insertion d’un tube nasotrachéal, combinée à une fuite provoquée du ballonnet orotrachéal, peut améliorer la ventilation alvéolaire pendant la VOHF chez ces patients.
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Supported by the Department of Anesthesia, Sunnybrook and Women’s College Health Sciences Centre.
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Cooper, A.B., Islur, A., Gomez, M. et al. Hypercapnic respiratory failure and partial upper airway obstruction during high frequency oscillatory ventilation in an adult burn patient. Can J Anesth 49, 724–728 (2002). https://doi.org/10.1007/BF03017453
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DOI: https://doi.org/10.1007/BF03017453