Feasibility of asynchronous independent lung high-frequency oscillatory ventilation in the management of acute hypoxemic respiratory failure: A case report

Objective: To report the first case of the use of asynchronous independent lung high-frequency oscillatory ventilation (AIL-HFOV) in the management of acute hypoxemic respiratory failure in a large pediatric patient with markedly asymmetric lung disease. Design: Case study. Setting: Tertiary pediatric intensive care unit in a pediatric teaching hospital. Patient: A 17-yr-old, 87-kg male patient with trisomy 21 and with respiratory failure and progressive hypoxemia because of pneumonia. Interventions: Intubation with a 37-Fr double-lumen endobronchial tube and ventilation with two oscillatory ventilators for a total of 16 days. Measurements and Main Results: Hemodynamic data were obtained using a pulmonary artery catheter. Adequate oxygenation and ventilation were readily achieved after institution of AIL-HFOV. The Flo₂/Pao₂ ratio increased from 52 to 224, and the shunt fraction decreased from 40 to 9 after 30 mins of AIL-HFOV. Flo₂ was rapidly reduced from 1.0 to 0.4 on the right lung and to 0.6 on the left lung. Mean arterial pressure was maintained, the cardiac index increased from 3.5 to 5.4 L/min/m², the systemic vascular resistance index decreased from 1513 to 1225 dyne-sec/ cm⁵·m², and the pulmonary vascular resistance index decreased from 723 to 428 dyne-sec/cm⁵·m² without the need for additional fluid boluses or increases in inotropic support. No airleaks developed during the entire hospital stay. Conclusions: AIL-HFOV improved oxygenation and hemodynamic performance in this large patient. This case demonstrates that it is feasible to use two high-frequency oscillatory ventilators to independently ventilate the lungs of a large patient with markedly asymmetric lung disease. We believe that AIL-HFOV deserves future study and development for the treatment of large patients with acute hypoxemic respiratory failure and asymmetric lung disease when other choices are limited.