Ventilator-Associated Necrotizing Tracheobronchitis in a Patient on High-Frequency Oscillatory Ventilation

Abstract

High-frequency oscillatory ventilation (HFOV) is used extensively in the neonatal population. In adults, it is still considered an alternative mode of ventilation for cases of severe acute respiratory distress syndrome refractory to conventional mechanical ventilation (CMV). Reported complications with HFOV among adults include pneumothorax, pneumomediastinum, and subcutaneous emphysema. Ventilator-associated necrotizing tracheobronchitis (VANTB) is a well-documented complication with HFOV in neonates. In adults, only 11 cases have been reported, 9 patients on high-frequency jet ventilation, and 2 patients on CMV. We report a case of VANTB in an adult on HFOV, discuss potential causes, and offer management options. (J Bronchol 2005;12:96-99) H igh-frequency oscillatory ventilation (HFOV) is an alternate ventilator mode designed to optimize alveolar volume recruitment in patients with refractory hypoxemia. HFOV applies a constant mean airway pressure (mPaw) much like a conventional continuous positive airway pressure (CPAP) by using rapid cyclic pressure changes generated by an electromagnetic piston. This constant mPaw allows for an ''open lung'' while avoiding low end-expiratory pressures and high peak pressures. 1 Studies of HFOV in neonates demonstrate an improvement in oxygenation without an increased incidence of barotrauma or histopathologic evidence of ventilator-induced lung injury. 2 Recent findings have suggested that intervention early in the course of adult acute respiratory distress syndrome (ARDS) with HFOV may be beneficial. 1,3 Most observational studies have initiated HFOV in severe ARDS after the patient has been designated a conventional mechanical ventilation (CMV) failure. In a multicenter, randomized, controlled trial of HFOV in ARDS, Derdak demonstrated a greater improvement in oxygenation over CMV, although this difference was not sustained beyond 24 hours. 2 In a recent review, pneumothorax, pneumomediastinum, and subcutaneous emphysema are listed as potential complications associated with this mode. 3 To date, no cases of ventilator-associated necrotizing tracheobronchitis (VANTB) have been reported in association with HFOV. CASE REPORTA 41-year-old, previously healthy man presented with signs and symptoms of an acute abdomen and underwent appendectomy; the appendix was normal on pathologic examination. His immediate postoperative course was complicated by daily fevers. On the fifth hospital day, broad-spectrum antibiotics were initiated for progressively worsening hypoxemia and diffuse bilateral infiltrates on his chest radiograph. He was noted to have cervical and supraclavicular lymphadenopathy, and a computed tomography (CT) scan revealed diffuse interstitial infiltrates with mediastinal adenopathy. An excisional biopsy of the supraclavicular lymph nodes revealed anaplastic T cell lymphoma. On the eighth hospital day, he was transferred to the intensive-care unit (ICU) and intubated for hypoxemic respiratory failure with worsening pulmonary infiltrates. A chemotherapy regimen cons...

Obstructive Fibrinous Tracheal Pseudomembrane Following Repeated Intratracheal Interventions

“… 8 Necrotizing tracheobronchitis may also be distinguished from OFTP, which has been described in association with mechanical ventilation. 9 The injury of necrotizing tracheobronchitis is not limited to the area near the tip of the endotracheal tube, but also extends into the lower trachea and bronchi. 10 Ventilator-associated necrotizing tracheobronchitis is believed to be associated with insufficient humidification, excessive airway temperature, submucosal ischemia, and high operating pressure.…”

“… 10 Ventilator-associated necrotizing tracheobronchitis is believed to be associated with insufficient humidification, excessive airway temperature, submucosal ischemia, and high operating pressure. 9 …”

“…10 Ventilator-associated necrotizing tracheobronchitis is believed to be associated with insufficient humidification, excessive airway temperature, submucosal ischemia, and high operating pressure. 9 The exact incidence of OFTP is unknown. The symptoms of OFTP may occur anywhere from a few hours to several days after extubation, as reported in previous studies.…”