Case reports

Daniela Perrotta, Francesca Stoppa, Marco Marano, Caterina Tomasello, Corrado Cecchetti, Elisabetta Pasotti, Francesca Iodice, Nicola Pirozzi

Emergency and Admissions Department - Red Zone
Bambino Gesù Pediatric Hospital, IRCCS Rome

INTRODUCTION

Lung contusion (LC), the most common form of parenchymal damage in pediatric closed-chest injuries, is characterized by hypoxemia with respiratory insufficiency, 50% of cases are also complicated by pneumonia and ARDS.
In single lung injuries, the mechanical ventilation performed using conventional tracheal intubation, in order to guarantee an adequate respiratory gas exchange, can require high pressure levels and high Tidal Volumes, leading to barotrauma and volutrauma in the healthy parenchyma and actually prolonging the duration of the mechanical ventilation itself, risking superinfection of the injured part. Literature contains hypotheses dating back to the 1990s correlating ARDS with qualitative and quantitative alterations of the surfactant deriving from damage to the alveolocapillary membrane and to the pneumocytes.

CASE STUDY

An 8-month-old patient, weighing 8 kg, was transferred to our PICU from an extra-regional hospital 24 hours subsequent to a closed-chest injury and transverse medullary lesion to C6-C7 (Sciwora), following a serious car accident.

When the patient arrived in the unit, already under conventional mechanical ventilation, he presented a radiographic chest picture compatible with pulmonary contusion in the lower left lung field with multiple homolateral rib fractures (IVX). These findings were confirmed by a computerized tomography of the chest, which quantified the level of parenchymal contusion at over 80% of the lower left lobe.

TREATMENT

We proceeded with selective nasal intubation, positioning an endotracheal tube in the main right bronchus and one in the trachea for the left lung, and placed the patient under controlled mechanical ventilation (PC) with two non-synchronized Servo 300 Screen respirators with different ventilatory settings and FiO₂ for the two lungs (figure 1).
Respiratory parameters were monitored continuously and the PaO₂/FiO₂ ratio was evaluated during the entire ILV period. After 24 hours of independent lung ventilation, it was possible to reduce the PEEP set for the injured lung and, in order to promote alveolar recruitment before proceeding to conventional mechanical ventilation, the patient underwent treatment with porcine surfactant (30mg/kg), selectively instilled into the contused lung.

Three hours after administration of the surfactant, we re-established pulmonary ventilation with one tube and ventilatory parameters gradually improved. The lung CT scan, conducted 48 hours later, showed an improvement in the pulmonary picture, the contused lung area being significantly reduced (<30%).

DISCUSSION

ILV, associated with selective administration of porcine surfactant to the contused lung, can contribute to a speedier recovery of the injured parenchyma and reduce the risk of superinfections, limiting the duration of ventilatory assistance. In fact, the clinical trials conducted on adult patients with RDS demonstrate that the administration of porcine surfactant stabilizes the alveolar wall, preventing it from collapsing.

REFERENCES

1. Cinnella G, Dambrosio M, Brienza N et al. Compliance and Capnography Monitoring during Independent Lung Ventilation: Report of Two Cases. Anesthesiology. 2000 Jul;93(1):275-8.
2. Frame SB, Marshall WJ, Clifford TG. Synchronized independent lung ventilation in the management of pediatric unilateral pulmonary contusion: case report. J Trauma 1989 Mar; 29(3):395-397
3. Frerking I, Gunther A, Seeger W, et al. Pulmonary surfactant: functions, abnormalities and therapeutic options. Intensive Care Med. 2001 Nov;27(11):1699-717.
4. Nakamura CT, Ripka JF, McVeigh K et al. Bronchoscopic instillation of surfactant in acute respiratory distress syndrome. Pediatr Pulmonol. 2001 Apr;31(4):317-20.
5. Gunther A, Ruppert C, Schmidt R et al. Surfactant alteration and replacement in acute respiratory distress syndrome. Respir Res. 2001;2(6):353-64
6. Il Surfattante nella Patologia Respiratoria Acuta" Editor Nicola Dirozzi, Daniela Perrotta. Edizione fuori commercio Riservata ai Sigg.Medici SEEd srl in collaborazione con Chiesi Farmaceutici.

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