MANAGEMENT OF PERSISTENT HYPERTENSION OF
PERSISTENT HYPERTENSION IN THE NEWBORN USING HIGH FREQUENCY
Published March 13, 2001
Joseph D. Limauro M.Ed., R.R.T.
Dartmouth Hitchcock Medical Center
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A 38 week newborn was delivered via elective
c-section. The infant was large for gestational age weighing
4.0 kg and presented with cyanosis and significant respiratory
distress including tachypnia, retractions, nasal flaring and
poor oxygenation. The infant required manual ventilation with
CPAP via ambu bag. SpO2 remained less than 85% on 100% oxygen.
The initial chest x-ray suggested Respiratory Distress Syndrome.
There was no maternal history to suggest pneumonia.
The infant was intubated and given surfactant.
Initial ventilator settings were: Pressure Control Mode, rate
40, PIP 26 cmH2O, FiO2 1.00, and PEEP 5 cmH2O.The ABG with
these settings was pH 7.43, PCO2 37 mmHg and PO2 58 mmHg.
The infant continued to worsen over the next
4 hours. Ventilator settings were now: Pressure Control Mode,
rate 60, PIP 36 cmH2O, FiO2 1.00 and PEEP 5 cmH2O. ABG results
on these settings were: pH 7.34, PCO2 44 mmHg and PO2 46 mmHg.
The chest x-ray (CXR) (Figure 1) showed no
Due to the high PIP required with little
improvement in oxygenation, the decision was made to place
the infant on High Frequency Oscillation (HFO). Mean airway
pressure was titrated to achieve SpO2 100%. Settings on HFO
were: 10 Hz, Mean Paw 24.5 cmH2O, Delta P 42 cmH2O and FiO2
1.00. ABG results on these settings were: pH 7.42, PCO2 40
mmHg and PO2 94 mmHg.
The subsequent CXR (Figure 2) showed adequate
inflation to T-9 (9th rib). The endotrachial tube showed high
placement and was advanced 2 cm.
Over the next few hours oxygenation remained
stable with SpO2 remaining at 100%. A repeat CXR (Figure 3)
now showed hyperinflation to T-10 with flattened diaphragms.
ABG results were: pH 7.57, PCO2 24 mmHg and PO2 267 mmHg.
Mean Paw was slowly weaned over the next
few hours without loss of oxygenation and was now at 23 cmH2O.
A repeat CXR (Figure 4) was obtained showing lung inflation
back to T-9. Delta P was also weaned during this time and
was now 34 cmH2O.
Over the next 2 days mean Paw, delta P and
FiO2 continued to be weaned successfully. With the infant
down to a mean Paw of 14 cmH2O, delta P 22 cmH2O and FiO2
0.30, the infant was returned to conventional ventilation
on a Servo 300 on the following settings: SIMV mode, rate
40, PIP 25 cmH2O, FiO2 0.30, PEEP 5 cmH2O and Pressure Support
8 cmH2O. ABG results for these settings were: pH 7.51, PCO2
30 mmHg and PO2 125 mmHg.
Conventional ventilator settings were weaned
over the next day and a half. FiO2 was now at room air with
ventilator settings: SIMV mode, rate 15, PIP 19 cmH2O, PEEP
5 cmH2O and Pressure Support 8 cmH2O. Ventilator waveforms
(Figure 5 below) show good compliance. The infant was successfully
- Kinsella JP, Truog WE, Walsh WF,
et.al. Randomized, multicenter trial of inhaled nitric oxide
and high-frequency oscillatory ventilation in severe, persistent
pulmonary hypertension of the newborn. J Pediatr 1997 Jul;131(1
Pt 1):55-62. Considerations. 1998. Armonk, NY, Futura Publishing
- Kinsella JP, Abman SH. High-frquency
oscillatory ventilation augments the response to inhaled
nitric oxide in persistent pulmonary hypertension of the
newborn: Nitric Oxide Study Group. Chest 1998 Jul;114(1
- Donn SB. Neonatal and Pediatric
Pulmonary Graphics: Principles and Clinical Considerations.
1998. Armonk, NY, Futura Publishing Company, Inc.
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