10/1/1999

The pediatric patient with weak respiratory efforts and significant minute ventilation requirements represents a difficult ventilation challenge. This problem is compounded when this task is attempted at home. This is the case of a very difficult to ventilate pediatric patient with severe neurologic disease and unique ventilation challenges.

This patient was diagnosed with brainstem and spinal teratoma during the prenatal period. She was born on January 9th, 1997 and required immediate surgical intervention. Her initial surgery was complicated and she required CPR in the operation room. She was discharged and over the next several months required multiple admissions for seizures and apnea. In June of 1997 she underwent radical surgery for removal of the spinal teratoma. She became ventilator dependent following this procedure.

A tracheostomy was placed and the patient was sent home in July of 1997 using a non-invasive ventilator (Bi-PAP STD). This technique was successful for a short time. However, during seizures, the pressure limited mode of ventilation failed to provide adequate tidal volumes and hypoxemia and hypercarbia were common during these episodes. On several occasions, resuscitation was required following failed ventilation during a seizure. She developed difficulty triggering the Bi-PAP device and was transitioned to a 335 Knightstar non-invasive ventilation device (Puritan Bennett). During this time she had multiple admissions for seizures and ventilatory failure due to inability of the pressure limited ventilators to provide ventilation during seizure activity.

She was readmitted in April of 1999 with atelectasis and also required revision of her VP shunt. Her neurologic status diminished and diaphragmatic movement was absent. Measured negative inspiratory force was -1 cmH2O. A cuffed Bivona tracheostomy tube was placed, a NIF of -1 cmH2O was measured, and an attempt at volume ventilation was made. Use of a traditional volume ventilator was discussed, but since we believed she would improve with time and begin to breathe spontaneously, use of an LP-6 of PLV 102 was ruled out.

She was place on an LTV1000 in the hospital in May of this year. Her settings were a respiratory rate of 26 breaths/min, PEEP of 4 cmH2O, flow sensitivity of 1 L/min, tidal volume of 135 mL, and inspiratory time of 0.8 seconds. Her ventilation was maintained and her blood gasses were normal. In fact, during her seizure activity, ventilation was maintained and the problems of hypoxemia and hypercarbia seen with the non-invasive devices were eliminated.

In June 1999 she began to have spontaneous breathing efforts and pressure support was added to support her efforts. At this time, her negative inspiratory force had increased to -14 cmH2O. She had no difficulty triggering the LTV1000 and the ability of the ventilator to maintain ventilation during the seizure periods was a significant advantage.

We decided to send her home on an LTV900 on SIMV+ pressure support to encourage her spontaneous breathing, but assure consistent minute volume delivery. She has been at home on the ventilator now for a couple of months and is doing quite well. The ability of the LTV to sense this small patient's efforts and have a minute volume guarantee, has been key to her successful transition to home.