title: Combination of extracorporeal membrane oxygenation and high-frequency oscillatory ventilation saved a child with severe ARDS after pulmonary resection.
abstract: We report a case in which a 2-year-old girl who underwent a right middle and lower lung lobectomy for congenital cystic adenomatoid malformation suffered massive bleeding and developed acute respiratory distress syndrome (ARDS) during the operation. She was ventilated with a high level of F(I)O(2) (0.75-1.0), PEEP (10-20 cmH(2)O), and PIP (33-55 cmH(2)O) to maintain SPO(2) (>90%). Following transfer to the ICU, continuous hemodialysis was introduced to reduce excessive blood volume. However, pulmonary oxygenation did not improve, and marked subcutaneous emphysema occurred on postoperative day 3 (POD 3). We introduced venovenous (V-V) extracorporeal membrane oxygenation (ECMO) to rest the lung, and V-V ECMO was changed to right and left atrial ECMO because of unsatisfactory oxygen support on POD 23. A CT scan showed almost the entire lung had collapsed, even though we had administered diuretics, steroids, nitric oxide, sivelestat, and surfactant for ARDS. We applied high-frequency oscillatory ventilation (HFOV) with a mean airway pressure of 20 cmH(2)O, frequency of 9.2 Hz, and amplitude of 38 cmH(2)O on POD 45. The collapsed lung was then gradually recruited, and pulmonary oxygenation improved (P/F ratio = 434). ECMO was successfully weaned on POD 88. The patient required a tracheostomy, but she was able to function without a ventilator on POD 142. Although HFOV has failed to show a mortality benefit in ARDS patients, the unique lung recruitment by HFOV can be a useful therapeutic option for severe ARDS patients in combination with sufficient lung rest produced by ECMO.
authors.affiliation: Department of Anesthesiology, Hirosaki University Postgraduate School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori 036-8562, Japan. ehashiba@pc4.so-net.ne.jp
authors.forename: Eiji
authors.initials: E
authors.lastname: Hashiba
authors.forename: Futoshi
authors.initials: F
authors.lastname: Kimura
authors.forename: Yasuyuki
authors.initials: Y
authors.lastname: Suzuki
authors.forename: Takeshi
authors.initials: T
authors.lastname: Asano
authors.forename: Tomoko
authors.initials: T
authors.lastname: Ono
authors.forename: Hirobumi
authors.initials: H
authors.lastname: Okawa
authors.forename: Toshihito
authors.initials: T
authors.lastname: Tsubo
authors.forename: Hironori
authors.initials: H
authors.lastname: Ishihara
authors.forename: Kazuyoshi
authors.initials: K
authors.lastname: Hirota
mesh_terms: D002675:Child, Preschool; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D006612:High-Frequency Ventilation / Q000379:methods*; D006801:Humans; D008168:Lung / Q000503:physiopathology / Q000601:surgery; D011013:Pneumonectomy / Q000009:adverse effects*; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000628:therapy*