The use of perfluorocarbon-associated gas exchange to improve ventilation and decrease mortality after inhalation injury in a neonatal swine model

doi:10.1016/S0022-3468(97)90177-9

Journal of Pediatric Surgery

Volume 32, Issue 2, February 1997, Pages 192-196

https://doi.org/10.1016/S0022-3468(97)90177-9 Get rights and content

Abstract

Patients with tracheobronchial disease frequently require mechanical ventilation during therapy and experience iatrogenic complications such as barotrauma and volutrauma. The purpose of this study was to determine whether perfluorocarbon-associated gas exchange (PAGE) results in lower ventilatory pressures and more efficient ventilation than that provided by conventional ventilation after tracheobronchial mucosal injury caused by smoke inhalation in neonatal piglets. Ten piglets were used for this prospective, randomized study. After administration of a severe smoke inhalation injury, the piglets were randomly assigned to either the perfluorocarbon or control groups. Group 1 served as the control population and received standard (time-cycled, volume-limited) mechanical ventilation. Ventilator settings were adjusted to maintain physiological pH and Po₂ at the lowest tidal volume, rate, and end-expiratory pressure possible throughout the study period. Group 2 was administered intratracheal perfluorocarbon as well as identical mechanical ventilation to attain the same physiological pH and Po₂. Oxygenation index, peak and mean airway pressures, and arterial blood gas levels were measured throughout the study period and subjected to statistical analysis. Histological comparison of airway and parenchymal tissues confirmed identical patterns of smoke injury in both groups. Carbon monoxide levels were the same in both groups. There was significant barotrauma and volutrauma in the control group, but none in the PAGE group. All controls died from 13 to 17 hours after injury; one PAGE pig died at 23 hours with all others surviving past 24 hours (P = .0021). Peak, plateau, and mean airway pressures were all significantly higher (P < .05) past 12 hours after injury and continued to increase until death in the controls. Arterial blood gases showed significantly (P < .05) decreased pH, Po₂, and elevated Pco₂ levels in the control group past 12 hours after injury. The oxygenation index was significantly elevated (P < .05) in the control group past 12 hours after injury. PAGE shows potential for improving ventilation and survival immediately after severe smoke inhalation injury and may have clinical applications in other nonhomogeneous lung injuries.

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Acute respiratory failure (ARF) continues to be the leading reason for pediatric intensive care unit (PICU) admission. Despite optimal management, death from respiratory failure continues to occur in patients who have severe aberrations in lung function. For example, mortality for acute respiratory distress syndrome (ARDS) in children has continued to be high (>50%).²¹ A myriad of innovative therapies are increasingly being utilized in attempts to improve patient outcome.¹⁶⁹ Many of these therapies were developed for pediatric patients or have achieved greater success and clinical application in critically ill children. Artificial surfactant is one such example that has revolutionized the field of neonatology. Inhaled nitric oxide (iNO) appears to be having a significant effect in many children who have congenital heart disease, persistent pulmonary hypertension of the newborn (PPHN), and congenital diaphragmatic hernia (CDH). Various methods of high-frequency ventilation (HFV) may improve the condition of some children who have respiratory failure and potentially decrease the number of children subjected to extracorporeal life support (ECLS). There are now well over 11,000 infants and 2,000 children who have received ECLS for severe cardiorespiratory failure with an overall survival in excess of 60%⁵; this technology, almost forgotten for two decades in adult intensive care, is again receiving attention in adults. Liquid ventilation (LV), an experimental method of respiratory support in which the subject's lungs are filled with a liquid perfluorochemical (PFC), was first applied in infants⁸⁴ and has thus far been employed in many more children than adult subjects. Despite this cornucopia of new therapies, few controlled trials have been conducted to guide the practitioner regarding the indications and the efficacy of these various modalities. Controversy has sparked several international consensus statements to form a framework for future discussion and investigation.3, 205, 243 This article focuses on two of these novel modalities: HFV and LV.
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Gas exchange and elastance were comparable among vaporized perfluorohexane, PLV, and GV before the open lung approach was used and improved in a similar fashion in all groups after positive end-expiratory pressure was adjusted to optimal elastance (P < 0.05). A similar behavior was observed in functional residual capacity (FRC) in animals treated with vaporized perfluorohexane and GV. Lung resistance improved after recruitment (P < 0.05), but values were higher in the 10% perfluorohexane and PLV groups as compared with GV (P < 0.05). Interestingly, positive end-expiratory pressure values required to obtain minimal elastance were lower with 5% perfluorohexane than with PLV and GV (P < 0.05). In addition, diffuse alveolar damage was significantly lower in the 5% and 10% perfluorohexane vapor groups as compared with PLV and GV (P < 0.05).
Although the use of 5% vaporized perfluorohexane permitted the authors to reduce pressures needed to stabilize the lungs and was associated with better histologic findings than were PLV and GV, none of these perfluorocarbon therapies improved gas exchange or lung mechanics as compared with GV.
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^☆: Presented at the 27th Annual Meeting of the American Pediatric Surgical Association, San Diego, California, May 20–23, 1996.

^☆☆: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

^★: Research was conducted in compliance with the Animal Welfare Act and other Federal statutes and regulations relating to animals and experiments involving animals and in adherence with the Guide for the Care and Use of Laboratory Animals, NIH publication 80-23, 1985 edition.

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The use of perfluorocarbon-associated gas exchange to improve ventilation and decrease mortality after inhalation injury in a neonatal swine model☆,☆☆,★

Abstract

Chest

J Pediatr

The risk of pneumonia in thermally injured patients requiring ventilatory support

J Burn Care Rehabil

Perfluorocarbon-associated gas exchange

Crit Care Med

Perfluorochemical liquid as a respiratory medium

Artif Cells Blood Substit Immobil Biotechnol

Experimental inhalation injury in the goat

J Trauma

The Use of Perfluorocarbon-associated Gas Exchange in Smoke Inhalation Injury