7.41 45 140 0.6 10 21 240 30 2,5 Page 3 of 5 Forti et al. Journal of Medical Case Reports 2010, 4:339 http://www.jmedicalcasereports.com/content/4/1/339 Table 1 Oxygenation and haemodynamic improvement Ph pCO2(mmHg) PaO2 (mmHg) FiO2(%) RVSWI (g-m/m2/beat) LVSWI (g-m/m2/beat) PVRI (dynes sec/cm5/m2) PAWP (mmHg) CI CV 7.51 49 89 1 19 28 267 32 2,7 7.48 47 190 1 14 17 190 24 2,7 7.44 46 189 0.8 7 16 192 25 2,7 7.4 43 145 0,6 7 17 195 25 2,6 HFPV after 2 hours HFPV after 6 hours HFPV after 12 hours CV after HFPV PaO2 rose from 90 to 190 mmHg with the same fractional inspiratory oxygen (FiO2) and positive end expiratory pressure level of conventional ventilation. Right ventricular stroke work index (RVSWI) lowered from 19 to 7. g-m/m2/beat, pulmonary vascular resistance index (PVRI) from 267 to 190 dynes sec/cm5/m2, left ventricular stroke work index (LVSWI) from 28 to 16 g-m/m2/ beat, pulmonary artery wedge pressure (PAWP) from 32 to 24 mmHg with a lower mean airway pressure than conventional ventilation. Cardiac index (2.7 L/min/ m2) and ejection fraction (EF) of 27% did not change. CV, conventional ventilation; HPFV, high frequency percussive ventilation. to ten we began bi-level positive airway pressure ventila- tion but it did not have an acceptable effect. On day 11 HFPV was started with: a 650/min percus- sive rate; a convective rate of 5/min; 14 cm H2O PEEP; 46 cm H2O PIP; 2.0 sec inspiratory time; 10.8 sec expiratory time; 16 cm H2O MArP; 1:7.0 inspiratory- expiratory (I:E) rate of conventional ventilation; and 1:1.0 I:E rate of the micro percussive burst. After only two hours of HFPV we noted an improvement of PaO2 from 90 to 190 mmHg with the same FiO2 and PEEP level of conventional ventilation. His right ventricular stroke work index (RVSWI) was lowered from 19 to 7 g-m/m2/beat, pulmonary vascular resistance index (PVRI) from 267 to 190 dynes sec/cm5/m2, left ventricu- lar stroke work index (LVSWI) from 28 to 16 g-m/m2/ beat, pulmonary artery wedge pressure (PAWP) from 32 to 24 mmHg with a lower MArP than with conventional ventilation. The cardiac index (2.7 L/min/m2) and ejec- tion fraction (EF) of 27% did not change. Diuresis was always maintained between 1-1.5 mL/kg/hour. After 12 Table 2 Ventilator setting pre- and post-high frequency percussive ventilation (HFPV) VGRP pre HFPV VGRP after HFPV TV (mL) MArP (cm H2O) Respiratory rate (rate/min) FiO2 (%) PEEP (cm H2O) PIP (cm H2O) Inspiratory-expiratory rate 600 24 12 1 14 38 1:1.5 750 20 12 0.6 14 34 1:1.5 After 12 hours of HFPV, tidal volume (TV) increased from 600 to 750 mL, mean airway pressure (MArP) lowered from 18 to 16 cmH2O, fractional inspiratory oxygen (FiO2) from 1 to 0.6%, peak inspiratory pressure (PIP) from 38 to 36 cmH2O. hours of HFPV the tidal volume increased from 600 to 750 mL, MArP was lowered from 24 to 20 cmH2O, FiO2 from 1% to 0.6% and PIP from 38 to 34 cmH2O, with conventional ventilation. After 12 hours of HFPV we reconnected the patient to the conventional ventila- tion and ten hours later he was successfully extubated. Two days later he was admitted to the subintesive care unit. We noted that HFPV (Percussionaire Bird Technolo- gies, ID, US) improved oxygenation and it had an effect after only two hours of therapy. Reper et al. [7] show the same results in a burn patient. Another study showed better secretion clearance and outcome when using HFPV during thoracotomy [8]. Both these mechanisms improve gas exchange. Swan Ganz catheter with a Vigilance© (Edward, CA, US) monitor was used to measure cardiac output and systemic and pulmonary pressures. We detected the haemodynamic and respira- tory parameter after two, six and 12 hours of unconven- tional ventilation therapy (Tables 1, 2 and 3). The chest X-ray (Figures 1 and 2) shows an improve- ment on the right lung compared to the preceding day and after only 12 hours of HFPV. Figure 3 shows the PaO2 increasing after HFPV. Compared to conventional ventilation, HFPV gave an improved PaO2 of from 90 to 190 mmHg after only two hours and with the same PEEP and FiO2 level as con- ventional ventilation. Velmahos et al. [9] reported a ser- ies of 32 adult medical and surgical intensive-care unit patients with acute lung distress syndrome who were failing with conventional ventilation (CV). In our case, the mean PaO2/FiO2 on CV was 111, which was improved to 163 after one hour by converting to HFPV and 193 at 48 hours. PIP decreased from 42.4 cm H2O on CV to 33.2 cm H2O after one hour of HFPV and 32.5 at 48 hours, but the MArP increased from 21 cm