A Brain Death Dilemma: Apnea Testing While on High-Frequency Oscillatory Ventilation

Apnea testing is an essential component of the evaluation to determine death by neurologic criteria (brain death).1 Advancing life support technologies can, however, blur the distinction between irreversible coma and brain death, thus presenting challenges to the application of current brain death criteria. Herein we report on a child who met all components for the determination of brain death except for a positive apnea test. This element of the evaluation could not be performed because the child’s oxygenation was achieved via high-frequency oscillatory ventilation (HFOV) and discontinuing such support would presumably lead to lung collapse, hypoxia, and sudden changes in pulmonary vascular resistance leading to cardiac compromise. This case highlights a dilemma that clinicians may face when following the guidelines to determine if a patient, on the basis of neurologic criteria, has died. A 4-year-old girl was brought to our hospital after being found unconscious. On arrival, the girl’s Glasgow Coma Scale score was 3, and mechanical ventilation was instituted. The clinical presentation and the computed tomographic scan of the head pointed to trauma as the cause for the child’s obtundation. Because the child’s condition continued to deteriorate, especially the ability to maintain adequate oxygenation, HFOV was initiated. Based on the clinical suspicion that the child’s condition was compatible with the diagnosis of brain death, we were asked to assess her. The clinical … Address correspondence to Margie A. Ream, MD, PhD, Division of Child Neurology, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH 43205. E-mail: margie.ream{at}nationwidechildrens.org