2003 OPEN FORUM Abstracts
A CASE STUDY: the role of ipv in the recruitment of a totally atelectatic lung During Mechanical Ventilation
Ken Hargett BS RRT, Michael J Hewitt RRT, Adaani E Frost, MD, Brian Timon BS,
RRT, Raymond Wolff RRT, Respiratory Care Services, The Methodist Hospital, Houston,
Introduction: Intrapulmonary Percussive Ventilation (IPV) has been widely used in the past in the management of hospitalized Cystic Fibrosis patients. Little has been reported on the use of IPV in ventilated patients. Recently we have begun using IPV for clearance of secretions in conjunction with mechanical ventilation. We present a case where IPV was used to facilitate drainage of small airway secretions and recruitment of a totally atelectatic lung in a critically ill patient.
Case Summary: The patient was a 34 year old white female with a history of severe Primary Pulmonary Hypertension. She presented to the Emergency Department as a critically ill patient with an altered level of consciousness, profound hypoxemia, and early renal impairment. On radiologic exam, an essentially clear right lung and a near totally atelectatic left lung were appreciated; Complications included an impaired hemodynamic status. She was admitted, intubated and placed on the PB 840 in the Medical Intensive Care Unit. An emergent bronchoscopy was done with no secretions occluding the left main bronchus or its segments and subsegments seen. A moderate amount of watery brown secretions were seen in the distal left airways. Ventilator settings were reasonably normal except for FIO2 (100%) and PEEP level (10cmH2O). On this FIO2 and PEEP, the highest PaO2 level obtained was 58mmHg. Due to her basically unilateral process, static compliance (Cst) and Plateau Pressures (Pplt) were essentially normal. Options were discussed with the attending physician and we decided to do the following: 1) Raise the PEEP level to 15 cm and 2) initiate nebulizer treatments via Intrapulmonary Percussive Ventilation (IPV) to encourage recruitment of the atelectatic lung. It was further decided that for the increased PEEP and IPV to be successful, we needed to turn the patient on her right side, with the "normal" lung down. We hypothesized that this would splint the good lung, help redirect a portion of the shunted blood flow, and let the added PEEP and IPV serve as recruitment tools for the collapsed lung. After the patient was turned right side down, the PEEP level was increased to 15cmH2O and the IPV treatment was begun. The cuff on her ETT was deflated so that a leak was detected, enhancing the movement of secretions. IPV treatments were scheduled q4 hours. Within 5 minutes of initiating the first treatment, a moderate to large amount of very thick brown secretions were seen in the ETT and suctioned clear. The patient's saturation readings increased from a starting point of 88% to 97% at the conclusion of the first treatment. One hour after the first treatment, an ABG was obtained and the patients PaO2 had increased from 58 mmHg to 93 mmHg. Repeat CXR following the second IPV treatment demonstrated a significant re-expansion of the left lung. At no point in her stay did the patient experience respiratory acidosis. The patient continued to improve from a hemodynamic and oxygenation standpoint over the next several days. Resumption of supine ventilation resulted in some recurrent left sided atelectasis. Right side dependent ventilation and IPV were resumed and again, her left lung showed improved aeration on radiologic exam. Continued treatments prevented Atelectasis or secretion retention. This patient ultimately died of sepsis related complications of her progressive renal disease and pulmonary hypertension.
Discussion: The clinical course of this patient clearly demonstrated the utility of IPV for lung recruitment and secretion clearance in a mechanically ventilated hemodynamically compromised patient with focal, unilateral atelectasis where conventional approaches, such as CPT and assisted coughing were ineffective. A formalized investigation of this application would be appropriate.