The Science Journal of the American Association for Respiratory Care

2002 OPEN FORUM Abstracts


Zack Frazier BS, RRT, Kelly Joplin RRT, Martin Rohrer, BS, RRT, and Terrence Coulter MD. Cox Health Systems; Springfield, MO.

Introduction: The alveolar recruitment maneuver (ARM) has been proven to be an effective procedure that improves oxygenation in patients with acute respiratory distress syndrome. Its application in post-operative cardiac patients has been limited due to concerns of compromising cardiac output as a consequence of high levels of peak end-expiratory pressure (PEEP). Herein, we describe a case of alveolar recruitment in a post-operative cardiac patient who tolerated high levels of PEEP without causing hemodynamic instability.

Case Summary: A 74 year old female with no underlying lung disease presented to the SICU after a 7 hour surgery for a three vessel CABG and a mitral valve replacement. Initial ventilator settings of PC 20 for a Vt 650 (10ml/kg IBW), rate 12, PEEP 10, FIO2 1.0 resulted in an ABG @ 1949 hours of pH 7.27, PaCO2 35, PaO2 68. Although comfortable with the ARM in ALI/ARDS patients, we were hesitant to incorporate this into our open-heart ventilator protocol. Thus, PEEP was increased to 12 and repeat ABG @ 2050 hours noted a pH of 7.15, PaCO2 49, PaO2 30. As a consequence of her clinical decline, the cardiothoracic surgeon administered 3 amps of NaHCO3-, told us to ?warm up? the 1010 jet ventilator, and consulted a pulmonologist. Thirty minutes after bicarbonate administration and increasing PEEP to 15cm, the ABG revealed a corrected pH , however, PaO2 was 32 (FIO2 1.0). The pulmonologist increased PEEP to 18. Follow-up ABG @ 2245 hours revealed a pH 7.31, PaCO2 49, and PaO2 50. After discussing with the cardiothoracic surgeon and assuring hemodynamic stability, the pulmonologist ordered a recruitment maneuver. The procedure began on PC 20, rate 10, PEEP 20, I:E 1:1 for 2 minutes. Observing good patient tolerance, a second recruitment maneuver was performed 15 minutes later, using a PEEP of 25. Finding this maneuver was also tolerated well, a third recruitment maneuver was done with a PEEP of 30 followed by an ABG 30 minutes later, resulting in a pH 7.36, PaCO2 46, PaO2 184. The ventilator settings at this point were PC 14 for a Vt of 450, rate 15, FIO2 1.0, PEEP 18. The patient?s P/F Ratio continued to improve and she was on an FIO2 .40 with a PaO2 of 100 the next day. Graphing the first eight post-op ABGs as related to Shunt %, PEEP, and P/F Ratio resulted in the following chart:

Discussion: This case demonstrates that the alveolar recruitment maneuver can be safe and effective in select post-operative cardiac patients. Further studies are needed to identify patients who would most likely benefit or be at high risk for complications from this procedure.


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