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CONTINUOUS NEGATIVE CHEST WALL PRESSURE (CNP) THERAPY IN OLDER CHILDREN

CNP provides an effective means of improving arterial oxygenation in spontaneously breathing patients. To date, this has been used mainly in infants with severe respiratory distress syndrome. Our purpose is to describe the application of CNP in older children with diffuse bilateral alveolar disease.An Emerson tank respirator was modified to apply continuous negative pressure of -5 to -18 cm H2O to chest wall and lower parts of the body in 4 patients, 5 to 10 years of age with severe P. carinii pneumonitis (PCP). Each patient had respiratory rate >70 per minute, PaO2 of <55 mm Hg breathing 50-60% of oxygen or higher and PaCO2 <40 mm Hg. Within 24 hours of institution of CNP, arterial oxygen tension rose from pre-CNP mean of 42.7 ± 11.4 to 98.2 ± 26.9 mm Hg, respiratory rate decreased from 87.7 ± 15.8 to 68.2 ± 18.5 and FIO2 from 60.25 ± 8.95 to 52.6 ± 7.3. In 2 patients in whom it was done, A-aDO2 gradient decreased from 589 and 545 to 425 and 416 mm Hg, and right to left shunt from 28 and 27% to 22 and 24%, respectively. Two patients developed pneumothorax that was successfully decompressed. Both had received CNP >16 mm Hg. Of the 4 patients, 2 recovered completely after 6 and 15.5 days of CNP therapy. Remaining 2, after 96 hours of improvement, developed progressive hypoxia and died. This is in contrast to 100% mortality in 5 other patients with severe PCP who were treated with volume-controlled positive pressure respirator.We conclude that CNP provides an effective means of improving arterial oxygenation in older children as well, reduces duration of exposure to high oxygen concentration and avoids use of endotracheal intubation.