High-frequency oscillatory ventilation and an interventional lung assist device to treat hypoxaemia and hypercapnia

A male patient accidentally aspirated paraffin oil when performing as a fire-eater. Severe acute respiratory distress syndrome (Pa-o2/Fi(o2) ratio 10.7 kPa) developed within 24 h. Conventional pressure-controlled ventilation (PCV) with high airway pressures and low tidal volumes failed to improve oxygenation. Hypercapnia (Pa-co2 12 kPa) with severe acidosis (pH<7.20) ensued. Treatment with high-frequency oscillatory ventilation (HFOV) and a higher adjusted airway pressure (35 cm H2O) improved the Pa-o2/Fi(o2) ratio within 1 h from 10.7 to 22.9 kPa, but the hypercapnia and acidosis continued. Stepwise reduction of the mean airway pressure (26 cm H2O), and oscillating frequencies (3.5 Hz), as well as increasing the oscillating amplitudes (95 cm H2O) resulted in an unchanged Pa-co2, but oxygenation worsened. The new pumpless extracorporeal interventional lung assist device (ILA, NovaLung(R), Hechingen, Germany) was therefore used for carbon dioxide elimination to enable a less aggressive ventilation strategy. Pa-co2 normalized after initiation of ILA. HFOV with a mean airway pressure of 32 cm H2O was maintained, but with a higher oscillatory frequency (9 Hz) and very low oscillatory amplitude (25 cm H2O). After 6 days, the patient was transferred to a conventional ventilator, and ILA was discontinued after 13 days without complications.