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Intratracheal pulmonary ventilation in premature infants and children with intractable hypercapnia
I R Makhoul1, G Bar-Joseph, S Blazer
1Department of Neonatology, Rambam Medical Center and The Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa.
Insights
Intratracheal pulmonary ventilation (ITPV) effectively reduced high carbon dioxide levels in critically ill neonatal and pediatric patients. While one infant survived, four too ill patients did not benefit long-term.
Area of Science:
- Pediatric Critical Care Medicine
- Neonatology
- Respiratory Physiology
Background:
- Uncontrollable hypercapnia poses a significant challenge in ventilated neonatal and pediatric patients.
- Conventional ventilation strategies may be insufficient for severe cases.
Purpose of the Study:
- To evaluate the feasibility and efficacy of intratracheal pulmonary ventilation (ITPV) in moribund neonatal and pediatric patients with intractable hypercapnia.
Main Methods:
- ITPV was applied using a specialized intratracheal catheter with reversed gas flow to flush CO2.
- The technique was tested in five neonates and pediatric patients with severe hypercapnia.
Main Results:
- ITPV achieved significant reductions in partial pressure of carbon dioxide (Paco2) by 37%-71% and improved pH within 4-6 hours.
- One premature infant survived and was discharged after successful weaning to conventional ventilation.
- Four patients with severe underlying conditions (shock, metabolic acidosis, coma) did not show substantial improvement and subsequently died.
Conclusions:
- ITPV is a feasible method for alleviating uncontrollable hypercapnia in ventilated neonatal and pediatric patients.
- Patient selection is critical, as those with severe comorbidities may not benefit from this intervention.
Abstract:
The feasibility of intratracheal pulmonary ventilation (ITPV) was tested in five ventilated moribund neonatal and pediatric patients with uncontrollable hypercapnia: a 2-year-old child, a 52-day-old infant, and three premature infants (29, 29, and 26 weeks gestation; 1300 g, 1100 g and 890 g birth weight, respectively). ITPV was applied for 9.5, 8, 25, 58.5, and 47.5 hr, respectively. An intratracheal catheter (Cook Critical Care, Inc., Bloomington, IN) with a reversed continuous flow of gas at its tip (away from the lungs) allowed flushing of CO2 from the proximal dead space. Marked reductions in Paco2, ranging from 37% to 71% and improvement in pH were achieved within 4-6 hr of applying ITPV. During ITPV, the mean lowest Paco2 was significantly less than the pre-ITPV Paco2 (p < 0.0017), and the mean best pH was significantly higher than the pre-ITPV pH (p < 0.015). In four patients, despite significant reductions in Paco2, there was no substantial improvement in their baseline condition (shock and severe metabolic acidosis or coma) and they were switched back to conventional ventilation. This led to worsening hypercapnia to pre-ITPV values. These four patients subsequently died. It is possible that these patients were already too ill to derive significant benefit from the technique. One premature infant survived, was successfully weaned to conventional ventilation and was eventually discharged home. ITPV can alleviate uncontrollable hypercapnia in ventilated neonatal and pediatric patients.