Continuous Positive Expiratory Pressure and Continuous High Frequency Oscillation in a patient with partial paralysis of hemidiaphragm following a motor vehicle accident
David Orloff, BS, RRT, Mari Stack, BS, RRT, Jen Domanoski, RRT, Samuel Thomas, MD, FAAP, Therese R. Dizon, BS, RRT
INTRODUCTION: Traditional Lung Expansion Therapy (TLET) (incentive spirometry, positive expiratory pressure (PEP), vibratory PEP) is used for secretion clearance and volume expansion. These devices, however, are effort dependent and can be ineffective in patients with weak respiratory effort. A pneumatically driven device, The MetaNeb® System (Hill-Rom) provides continuous positive expiratory pressure (CPEP) and continuous high frequency oscillation (CHFO) to enhance mucus clearance and treat / prevent atelectasis.
CASE SUMMARY: A 12-year-old female who was a partially restrained (lap belt only) backseat passenger in a motor vehicle accident (MVA). Initial chest x-ray (CXR) noted a left elevated hemi diaphragm and initial CT scan showed abdominal organs in the left chest cavity. Severe trauma to the lumbar spine (fracture of L3-L4 and almost complete transection extending to T11) was noted resulting in lower body paralysis along with evidence of extensive small bowel injuries. She was taken to the operating room for repair, anastomosis, and appendectomy.
Patient was admitted to the Pediatric ICU and remained intubated for 7 days. Due to her injuries, surgical repair to the left diaphragm, and pain control medications, inspiratory effort was weak and cough was nonproductive. Supplemental oxygen was given to maintain saturation above 90%. The post-extubation CXR revealed bilateral basilar atelectasis within one hour of extubation.
TLET’s were not used due to weak inspiratory effort. Lung expansion therapy with The MetaNeb® System was instituted using a mask interface to avoid reintubation. Patient initially tolerated only continuous positive expiratory pressure (CPEP) therapy for approximately 2-3 minutes Q4h. As therapy continued, tolerance improved and Continuous High Frequency Oscillation (CHFO) therapy was added. The patient was weaned to room air within 2 days of treatment and the post therapy CXR, at 4 days showed significant improvement.
DISCUSSION: Spinal cord injury patients are at risk of developing atelectasis and pneumonia [1]. This is particularly true in patients with diaphragmatic injury or paralysis [2]. TLET’s may be effective in many patients, but are dependent upon the patient’s ability to generate significant inspiratory effort and cough. In this case, CPEP and CHFO therapy provided an effective alternative for volume expansion and bronchial hygiene, helping to avoid reintubation in a patient with significant atelectasis and a weak cough.
- Lanig IS, Peterson WP. The respiratory system in spinal cord injury. Phys Med Rehabil Clin N Am. 2000; 11(1): 29-43.
- Burns SP. Acute respiratory infections in persons with spinal cord injury. Phys Med Rehabil Clin N Am. 2007; 18: 203-216.
For more information contact David Orloff, Director, Jersey Shore Medical Center.
