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A5280 - High-Flow Nasal Cannula Oxygen in Immunocompromised Patient with Acute Hypoxic Respiratory Failure
Author Block: K. Rajdev1, F. A. Siddiqui2, A. Siddiqui2, B. Joseph1, S. Habib1, D. El-Sayegh2; 1Internal Medicine, Staten Island University Hospital, Staten Island, NY, United States, 2Pulmonary and Critical Care Medicine, Staten Island University Hospital, Staten Island, NY, United States.
Introduction:
Acute hypoxic respiratory failure (AHRF) is a known complication of lung transplant recipients. Recurrent and polymicrobial infections are among the most common etiologies. There is no consensus on how to treat hypoxia in these patients, invasive mechanical ventilation (IMV) is often required but it increases the morbidity and mortality significantly. Noninvasive positive pressure ventilation (NPPV) has shown some promise but overall carries high failure rate. High flow nasal cannula (HFNC) has emerged as an alternative to IMV and NPPV. We present a case of a bilateral lung transplant recipient with severe neutropenic sepsis presented with AHRF, and HFNC was successfully used to avoid IMV.
Case Description:
A 77 y/o male with chronic respiratory failure on home O2, bilateral lung transplant due to pulmonary fibrosis, hypertension and diabetes presented with productive cough, fever and dyspnea of 1 week duration. He was discharged 4 weeks prior to presentation from his transplant hospital after being treated for CMV pneumonitis. His home medications included tacrolimus, prednisone, posaconazole and gancyclovir. He was tachypnic and in respiratory distress with O2 saturation of 84% on 5L O2. He was started on nonrebreather mask with 100% O2. Blood gas showed PaO2 60 and mild hypercapnia of 45 with a normal pH. Chest Xray revealed right lower lobe opacity. Meanwhile, he remained hypoxic to 89% on pulse oximetry. He didn't want to be intubated, therefore, was started on HFNC with flow of 60 L and 100% oxygen. His dyspnea and O2 saturation improved and he appeared comfortable. He was started on broad spectrum antibiotics. He responded well to HFNC and over the course of next 48hrs, his FiO2 was reduced to 0.6 with 50L gas flow. His blood, sputum and urine cultures came back negative, urine legionella and streptococcus antigen, CMV IgM antibody were also negative. On day 6 of his admission, he was switched to nasal cannula with 5 L oxygen and eventually transferred to the medicine floor.
Discussion:
Growing body of evidence suggests that the use of HFNC is associated with lower mortality and intubation rates as compared to standard O2 or NIV, in immunocompromised patients admitted to ICU for AHRF. However, these studies excluded the patients with chronic respiratory failure, underlying chronic lung disease and profound neutropenia.
We report this case because our patient had severe neutropenia, chronic lung disease and chronic respiratory failure and benefitted with the use of HFNC for AHRF.