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Hypercapnic respiratory failure and partial upper airway obstruction during high frequency oscillatory ventilation in an adult burn patient

[Défaillance respiratoire hypercapnique et obstruction partielle des voies respiratoires supérieures pendant la ventilation oscillatoire à haute fréquence chez un brûlé adulte]

Andrew B. Cooper, MD FRCP(C)^*, Avinash Islur, BSc, Manuel Gomez, MD MSc, Gordon L. Goldenson, MD FRCP(C)^* and Robert C. Cartotto, MD FRCS(C)

^* From the Departments of Anesthesia and Critical Care, and
Surgery, Sunnybrook and Women’s College Health Sciences Centre, and
the Department of Surgery, Ross Tilley Burn Centre, Toronto, Ontario, Canada.

Address correspondence to: Dr. Robert Cartotto, Ross Tilley Burn Centre, Sunnybrook and Women’s College Hospital, Room D712, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada. Phone: 416-480-6706; Fax: 416-480-6708; E-mail: Robert.Cartotto{at}swchsc.on.ca

Purpose: To present a case of severe hypercapnic respiratory failure in an adult burn patient and to describe our clinical problem solving approach during support with an unconventional mode of mechanical ventilation.

Clinical features: A 19-yr-old male with smoke inhalation and flame burns to 50% total body surface area was admitted to the Ross Tilley Burn Centre. High frequency oscillatory ventilation (HFOV) was initiated on day three for treatment of severe hypoxemia. By day four, the patient met consensus criteria for acute respiratory distress syndrome. On day nine, alveolar ventilation was severely compromised and was characterized by hypercapnea (PaC0₂ 136 mmHg) and acidosis (pH 7.10). Attempts to improve CO₂ elimination by a decrease in the HFOV oscillatory frequency and an increase in the amplitude pressure failed. An intentional orotracheal tube cuff leak was also ineffective. A 6.0-mm nasotracheal tube was inserted into the supraglottic hypopharynx to palliate presumed expiratory upper airway obstruction. After nasotracheal tube placement, an intentional cuff leak of the orotracheal tube improved ventilation (PaCO₂ 81 mmHg) and relieved the acidosis (pH 7.30). The improvement in ventilation (with normal oxygen saturation) was sustained until the patient’s death from multiple organ dysfunction four days later.

Conclusion: During HFOV in burn patients, postresuscitation edema of the supraglottic upper airway may cause expiratory upper airway obstruction. The insertion of a nasotracheal tube, combined with an intentional orotracheal cuff leak may improve alveolar ventilation during HFOV in such patients.