経肺圧を指標としたPEEP設定により，致死的低酸素血症から改善した神経芽細胞腫に伴う腹部コンパートメント症候群の一乳児症例

Background : Neuroblastoma is the most common extracranial solid tumor of childhood. Although the prognosis of neuroblastoma is relatively good, newborns less than two months of age with stage 4S neuroblastoma may present with aggressive hypoxia and restrictive respiratory impairment due to abdominal compartment syndrome.
Case presentation : Two-month-old girl, height of 63 cm and body weight of 10 kg. She was diagnosed as neuroblastoma with Stage 4S. Because she was suffered from refractory hypoxemia and restrictive respiratory impairment due to abdominal compartment syndrome induced by multiple liver metastasis and massive ascites, she was transferred to our ICU. Her trachea was intubated and ventilated with assist/controlled mode, driving pressure 22 cmH2O, positive end-expiratory pressure（PEEP）8 cmH2O, fraction of inspiratory oxygen（FIO2）1.0, but tidal volume was obtained only 3.2 mL/kg and PaO2/FIO2 ratio of 55 mmHg. Therefore, we insert esophageal sensor and monitored esophageal pressure to performed transpulmonary pressure guided PEEP titration. When we changed PEEP from 8 to 15 cmH2O so that the end-expiratory transpulmonary pressure achieving 0 to 5 cmH2O, her oxygenation（PaO2/FIO2 ratio : 55 to 178 mmHg）and respiratory compliance（1.4 to 3.0 mL/cmH2O）were dramatically improved. Her respiratory condition was further stabilized by ascites puncture and radiotherapy, and the patient was extubated successfully on the 25th ICU day.
Conclusions : Although pediatric neuroblastoma with stage 4S may induce severe respiratory efficiency, the responsiveness of treatment for neuroblastoma is promising. Multimodal treatments including optimal ventilator management such as transpulmonary pressure -guided PEEP titration contributes to improved patient’s prognosis.