(1143) High-Flow Oxygen Therapy via Tracheostomy to Wean From Prolonged Mechanical Ventilation

Introduction: Guillain Barre Syndrome (GBS) is an autoimmune condition that can cause life-threatening respiratory failure, necessitating prolonged mechanical ventilation (MV). High-flow oxygen therapy (HFOT) delivered via nasal cannulae provides humidified and warm gas mixture which enhances mucociliary function and reduces upper airway resistance, and PEEP which leads to improved oxygenation and work of breathing. HFOT can also be administered to a tracheostomy opening with an adapter although evidence for its benefit in difficult-to-wean tracheostomized patients is scarce.

Description: A 60-year-old male with acute myeloid leukemia underwent allogeneic stem cell transplantation and achieved complete remission. Six months post-transplant, his course was complicated by adenovirus infection and ascending paresthesia and weakness. LP showed elevated cerebrospinal fluid protein (1300 mg/dL) and electromyography was consistent with axonal GBS. He received Rituximab and IV immunoglobulin. He subsequently developed respiratory failure with negative inspiratory force (NIF) of -15 cm H2O requiring intubation and MV. After 11 days of MV and failed weaning trials, a percutaneous tracheostomy was done. After several weeks, despite tolerating low levels of pressure support (PS) and 40% FiO2 with NIF of -23 to -29, there were repeated failed trials of tracheostomy collar. On day 74 of MV, HFOT via tracheal adapter with 50% FiO2 at 60 L/min was introduced daily for 4-6 h and gradually increased. By day 99, he tolerated 24 h off MV on HFOT. The tracheostomy tube cuff was deflated and 48 h later, he was transitioned to conventional weaning with tracheostomy collar during the day and PS at night. After 5 months on the ventilator, he was decannulated, and subsequently discharged to a rehabilitation facility and was home 3 months later.

Discussion: Our case highlights successful use of HFOT via tracheostomy in a difficult-to-wean patient with Guillain-Barre Syndrome. The underlying mechanism and benefits of HFOT via tracheostomy remain poorly understood but may be related to the reduction in inspiratory effort and enhancement of tidal volume by delivering high flow oxygen. Larger studies are needed to confirm the efficacy of HFOT via tracheostomy in weaning patients from prolonged MV due to neuromuscular disease.