Resp Care
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We report the successful weaning and extubation of an infant from a SensorMedics 3100A high-frequency oscillator without returning to conventional ventilation. A 7-week-old term infant with respiratory syncytial virus bronchiolitis complicated by cystic pulmonary lesions repeatedly failed attempts to return to conventional ventilation from high-frequency oscillatory ventilation (HFOV) for weaning, because of recurrent pneumothoraces. A computed tomography of the chest revealed multiple well defined cysts of various sizes involving both lungs. ⋯ The weaning strategy consisted of a technique we refer to as "sprinting." Using this method, the patient was successfully extubated directly from HFOV, with no complications. A follow-up computed tomography of the chest showed marked improvement in the size of the cystic lesions. The patient was discharged home with no need for home oxygen therapy.
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There is clinical interest in the use of heliox (helium-oxygen mixture) during noninvasive positive pressure ventilation (NPPV), but delivery of heliox with ventilators designed for NPPV has not been reported. We studied helium concentration ([He]) when an 80%:20% helium:oxygen mixture (heliox) was used with 5 NPPV ventilators (Knightstar, Quantum, BiPAP S/T-D30, Sullivan, and BiPAP Vision). ⋯ Heliox flow was the most important determinant of [He] when using heliox with NPPV. With heliox there was a potential for ventilator malfunction in some conditions. The clinical implications of these findings remain to be determined.
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In order to use tracheal gas insufflation (TGI) in a safe and effective manner, it is important to understand potential interactions between TGI and the mechanical ventilator that may impact upon gas delivery and carbon dioxide (CO2) elimination. Furthermore, potentially serious complications secondary to insufflation of cool, dry gas directly into the airway and the possibility of tube occlusion must be considered during use of this adjunct modality to mechanical ventilation. Regardless of the delivery modality (continuous TGI, expiratory TGI, reverse TGI, or bidirectional TGI), conventional respiratory monitoring is required. ⋯ Therefore, depending on the gas delivery technique used, it is important to carefully monitor these ventilatory parameters for TGI-induced changes and understand the potential need for adjustments to ventilator settings to facilitate therapy and avoid problems. Optimally, gas insufflated by the TGI catheter should be conditioned by addition of heat and humidity to prevent mucus plug formation and potential damage to the tracheal mucosa. Finally, patients must be closely monitored for increases in peak inspiratory pressure from obstruction of the tracheal tube and should have the TGI catheter removed and inspected every 8-12 hours to assess for plugs.