High-flow oxygen via tracheostomy facilitates weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction: two case reports

Abstract

BackgroundWeaning from prolonged mechanical ventilation is extremely difficult in tracheostomized patients with restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy supplies heated and humidified oxygen gas at > 10 L/minute. However, little has been reported on the use of high-flow oxygen via tracheostomy during weaning from ventilators in patients with restrictive pulmonary dysfunction. We report successful weaning from ventilators in patients with restrictive pulmonary dysfunction using high-flow oxygen via tracheostomy.Case presentationThe first patient is a 78-year-old Japanese man with severe pneumococcal pneumonia who was mechanically ventilated for more than 1 month after esophagectomy for esophageal cancer. After he underwent tracheostomy because of prolonged mechanical ventilation, restrictive pulmonary dysfunction appeared: tidal volume 230–240 mL and static compliance 14–15 mL/cmH2O with 10 cmH2O pressure support ventilation. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 16 days (flow at 40 L/minute and fraction of inspired oxygen of 0.25). The second patient is a 69-year-old Japanese man who developed aspiration pneumonia after esophagectomy and received prolonged mechanical ventilation via tracheostomy. He developed restrictive pulmonary dysfunction. High-flow oxygen via tracheostomy (flow at 40 L/minute with fraction of inspired oxygen of 0.25) was administered with measurement of the airway pressure and at the entrance of the tracheostomy tube. The measured values were as follows: 0.21–0.3 cmH2O, 0.21–0.56 cmH2O, 0.54–0.91 cmH2O, 0.76–2.01 cmH2O, 1.17–2.01 cmH2O, and 1.76–2.01 cmH2O at 10 L/minute, 20 L/minute, 30 L/minute, 40 L/minute, 50 L/minute, and 60 L/minute, respectively. The airway pressures were continuously positive and did not become negative even during inspiration, suggesting that high-flow oxygen via tracheostomy reduces inspiratory effort. He was weaned from the ventilator under inspiratory support with high-flow oxygen via tracheostomy over a period of 12 days.ConclusionsHigh-flow oxygen via tracheostomy may reduce the inspiratory effort and enhance tidal volume by delivering high-flow oxygen and facilitate weaning from prolonged mechanical ventilation in patients with restrictive pulmonary dysfunction.

How Much PEEP Does High Flow Deliver via Tracheostomy? A Literature Review and Benchtop Experiment

“…Our experiment showed that HFT generates approximately 0.3, 0.5, and 0.9 cmH 2 O of pPEEP with flows of 40 L/min, 50 L/min, and 60 L/min, respectively. The magnitude of these measures corresponds reasonably with previous studies of airway pressure in previous studies [ 13 , 15 ].…”

“…Evidence for improved CO 2 clearance with HFT is limited to the Mitaka case report. The authors suggest the presence of restrictive lung disease may have played a role [ 15 ]. Whether HFT offers an advantage for restrictive lung pathology where any dead space washout is likely to be proportionally greater may be explored in future work.…”

“…Mitaka et al described 2 cases where HFT was used to apparent effect in weaning patients with restrictive lung pathology from ventilatory support [ 15 ]. In the first case, a 78-year-old man with postoperative pneumococcal pneumonia, who subsequently developed restrictive lung dysfunction ( C static 14–15 mL/cmH 2 O, TV 230–240 ml) was successfully weaned off ventilator support over 16 days with HFT at 40 L/min.…”

High-flow Tracheal Oxygenation: A New Tool for Difficult Weaning

“…Recently, Mitaka et al reported successful weaning of two PMV patients with restrictive pulmonary function. 16 He observed that high inspiratory oxygen flow facilitates weaning by enhancing tidal volume and reducing their inspiratory efforts and work of breathing. He further suggested that in contrast to their study, Corley et al, failed to exhibit an increase in EELV as their patients were more generalized and lacked any restrictive pulmonary dysfunction.…”

High-flow tracheal oxygen: what is the current evidence?

“…HFT provides superior optimal humidification than does COT, which supplies cold and dry oxygen flow. Mitaka et al presented two cases report demonstrating that HFT facilitates weaning from prolonged mechanical ventilation (PMV) in patients with restrictive lung disease [16]. Few studies have compared HFT and COT with respect to clinical performance (Table 1).…”