Cartotto R, Cooper A B, Esmond J R, Gomez M, Fish J S, Smith T
The Ross Tilley Burn Center, Sunnybrook and Women's College Health Sciences Center, Toronto, Ontario, Canada.
J Burn Care Rehabil. 2001 Sep-Oct;22(5):325-33. doi: 10.1097/00004630-200109000-00006.
Lung protective ventilation strategies are recommended in acute respiratory distress syndrome to avoid ventilator associated lung injury, a recently characterized complication of mechanical ventilation. High-frequency oscillatory ventilation (HFOV) is an unconventional ventilation strategy which may achieve this goal. We reviewed our experience with HFOV in six severely burned patients with acute respiratory distress syndrome. The mean age (+/- SD) of the patients was 34 +/- 13 years, and the mean TBSA burn was 52 +/- 10%, with a mean full-thickness injury of 49 +/- 12%. HFOV was initiated as "rescue therapy" in three patients with oxygenation failure (mean PaO2/FIO2 ratio of 71 +/- 8 and mean oxygenation index [OI] of 42 +/- 3) that was unresponsive to conventional ventilation (mean FIO2, 1.0 +/- 0; mean positive end expiratory pressure, 14.8 +/- 2.8 cm H2O; and mean inhaled nitric oxide, 20 +/- 0 ppm). In the other three cases, HFOV was initiated "prophylactically" as a lung protective ventilation strategy in an attempt to prevent further respiratory deterioration. All six patients showed a rapid and substantial improvement in oxygenation after initiation of HFOV, with significant improvements in the PaO2/FIO2 and OI by 12 hours (P = 0.02). In four patients HFOV was also used during anesthesia and surgery, where a total of 10 procedures involving a mean excision and closure of 15 +/- 7% TBSA burns was performed. Five of the six patients died, but none died because of oxygenation failure. In three patients death resulted from sepsis and multiple organ dysfunction syndrome; their mean PaO2/FIO2 was 107 +/- 31 and their mean OI was 30 +/- 11 immediately before death. Two patients with multiple organ dysfunction syndrome died after withdrawal of life support; their mean PaO2/FIO2 and OI were 178 +/- 31 and 18 +/- 2 respectively, at the time of this decision. Although HFOV had no impact on mortality, it played a useful role in the supportive management of burn patients with severe oxygenation failure unresponsive to conventional ventilation. Importantly, HFOV allowed surgery to proceed in patients who may have otherwise been too unstable to go to the operating room. As far as we are aware, this is the first report of the use of intraoperative HFOV in burn patients.
在急性呼吸窘迫综合征中推荐采用肺保护性通气策略，以避免呼吸机相关性肺损伤，这是一种最近才被认识到的机械通气并发症。高频振荡通气（HFOV）是一种非常规通气策略，可能实现这一目标。我们回顾了我们对6例患有急性呼吸窘迫综合征的严重烧伤患者应用HFOV的经验。患者的平均年龄（±标准差）为34±13岁，平均烧伤总面积为52±10%，平均深度烧伤面积为49±12%。3例氧合衰竭患者（平均动脉血氧分压/吸入氧分数比为71±8，平均氧合指数[OI]为42±3）对传统通气（平均吸入氧分数，1.0±0；平均呼气末正压，14.8±2.8 cmH₂O；平均吸入一氧化氮，20±0 ppm）无反应，开始将HFOV作为“挽救治疗”。在另外3例患者中，HFOV作为一种肺保护性通气策略“预防性”启动，试图防止进一步的呼吸功能恶化。所有6例患者在开始HFOV后氧合迅速且显著改善，12小时时动脉血氧分压/吸入氧分数比和OI显著改善（P = 0.02）。4例患者在麻醉和手术期间也使用了HFOV，共进行了10次手术，平均切除和闭合烧伤总面积为15±7%。6例患者中有5例死亡，但均非因氧合衰竭死亡。3例患者死于脓毒症和多器官功能障碍综合征；死亡前他们的平均动脉血氧分压/吸入氧分数比为107±31，平均OI为30±11。2例多器官功能障碍综合征患者在撤除生命支持后死亡；决定撤除生命支持时，他们的平均动脉血氧分压/吸入氧分数比和OI分别为178±31和18±2。虽然HFOV对死亡率没有影响，但它在对传统通气无反应的严重氧合衰竭烧伤患者的支持治疗中发挥了有益作用。重要的是，HFOV使那些可能因过于不稳定而无法进入手术室的患者能够进行手术。据我们所知，这是关于烧伤患者术中使用HFOV的首次报告。
