The Utilization of Non-Invasive Cardiac Output monitoring (NICO) in conjunction with mechanical ventilation and Inhaled Nitric Oxide (INO) for the treatment of Eisenmenger syndrome with respiratory failure.

Robert Lichtstein,BSRT,RRT-NPS, Andrew Brown,RRT-NPS, Brian Burlew,MD, Stephen Matchett,MD, Matthew McCambridge, MD, Kenneth Miller, MED, RRT-NPS, Jeffrey Marsh, MD Lehigh Valley Hospital and Health Network, Bethlehem, PA

Objective: To report a case of an adult with cardiac dysfunction that required advanced critical care monitoring in order to titrate mechanical ventilation requirements in the presence of respiratory decompensation.

Patient: Thirty-five year-old male with Down Syndrome and pulmonary hypertension with oxygen dependence developed respiratory insufficiency secondary to aspiration. Mechanical ventilation was instituted and the ARDSnet ventilator strategy was utilized. Inhaled nitric oxide was administration secondary to the high suspicion of pulmonary hypertension.

Intervention: ARDSnet ventilator strategy utilizing the Drager E-4 ventilator incorporated with INO and monitoring provided by NICO.

Results: The diagnosis of Acute Lung Injury (ALI) was difficult to discern secondary to the inability to measure left atrial pressure. Also the P/F ratio was difficult to interpret secondary to unrepaired Eisenmenger's syndrome congenital cardiac anomaly. NICO was deployed to assess the Volumetric carbon dioxide elimination (VCO2) as well as Pulmonary Capillary Blood Flow (PCBF). Also to evaluate the level of gas exchange including the deadspace to tidal volume ratio (Vd/Vt). By examining and utilizing trended information from NICO, a better understanding of the patient's clinical parameters allowed the critical care team to intervene and direct appropriate care. Over the next few days, the patient was liberated from mechanical support.

Conclusion: Acute lung injury secondary to acute aspiration in the presence of cardiac malfunction may require non-invasive cardiac monitoring to discern the effectiveness of therapy. In our opinion the use of NICO may be advantageous when the gold standard of hemodynamic monitoring is not possible or deployed.