Abstract
ABSTRACTObjective: To describe, for the first time in the pediatric population, the use of an effective technique to mobilize secretion in a patient whose disease imposes many care limitations.Case description: 2-year-old infant with Epidermolysis Bullosa, dependent on mechanical ventilation after cardiorespiratory arrest. Infant evolved with atelectasis in the right upper lobe with restriction to all manual secretion mobilization techniques due to the risk of worsening skin lesions. We opted for tracheal aspiration in a closed system combined with expiratory pause, a technique only described in adult patients so far.Comments: This case report is the first to use this technique in a pediatric patient. The use of expiratory pause combined with tracheal aspiration not only optimized the mobilization of secretion, but it was also a safe tool for reversing atelectasis. Our case report brings an important result because it increases the possibilities of managing pediatric patients admitted to intensive care units, especially in situations of absolute contraindication for chest maneuvers.
Highlights
Epidermolysis bullosa (EB) is characterized by changes in intraepidermal or dermoepidermal adhesion that result in the appearance of blisters on the skin in response to minor trauma.[1]
The need for invasive mechanical ventilation and the presence of an artificial airway are added, which increases the risk of accumulation of secretion due to impairment of the mucociliary clearance mechanism.[3]
Patients on mechanical ventilation have most of these physiological factors altered, which favors the accumulation of secretion and can bring complications, such as increased airway pressures, carbon dioxide retention, changes in ventilation/perfusion ratio (V/Q), drop in arterial oxygen saturation (SpO2), ventilation-associated pneumonia, and atelectasis.[7]
Summary
Epidermolysis bullosa (EB) is characterized by changes in intraepidermal or dermoepidermal adhesion that result in the appearance of blisters on the skin in response to minor trauma.[1]. One of the main advantages of the closed aspiration method is that it avoids depressurization of the system, but maintaining the inspiratory flow impairs the removal of secretion.[13,14] the use of expiratory pause associated with the closed aspiration system seems to be an interesting strategy to avoid depressurization of the system while guaranteeing secretion clearance In conditions such as EB and countless others that limit or prevent manipulation of the patient, tracheal aspiration with a closed system in association with expiratory pause emerges as an alternative with good applicability in the handling of patients in critical state admitted to the intensive care unit. Patient was seen at the institution without sedation to assess the evolution of the neurological condition after CRA, showing no response to pain and absence of cough reflex She was hemodynamically stable, without vasoactive drugs, OTI under mechanical ventilation in assisted/ controlled mode and controlled pressure (AC/CP): controlled pressure (CP): 14; end expiratory pressure (PEEP): 8; respiratory rate (RR): 30; FIO2: 50%; inspiratory time (Tinsp): 0.75 seconds; and tidal volume (TV): 11mL/kg. A control X-ray, after three physical therapy sessions with expiratory pause, showed total reversal of atelectasis in the right apex (Figure 1B)
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