2004 OPEN FORUM Abstracts
APRV AND PRESSURE CONTROL VENTILATION DURING INDEPENDENT LUNG VENTILATION (ILV) IN A PATIENT WITH A RIGHT MAINSTEM MASS. A CASE STUDY.
Richard Piekutowski RRT-NPS, Margaret M. Wojnar, M.D and Eric
Bakow MA, MPM, RRT. The Pennsylvania
State University’s Milton S. Hershey Medical Center, Hershey,
Patient data and case summary: The patient was a 57 year old male with a past medical history of persistent cough for 2 years, hemoptysis and emphysema. He has smoked for the past 30+ years. He was transferred to our facility with a Spo2 of 50% on a 100% non-rebreather. His blood gas, on a 100% non-rebreather was PH=7.42, PaCO2=36 torr, PaO2=35 torr, HCO3=23 mEq, BE=-1.3. After admission he became increasingly more hypoxic and hemodynamically unstable and was intubated with a single lumen 8.0 Endo-tracheal tube. A chest x-ray revealed an opacification of the right lung with a mediastinal shift. (see figure 1) A spiral CT of his chest, revealed a large right mainstem lesion, which was occluding his right mainstem bronchus. Upon his return to the MICU he was placed on Pressure control 35 cm H20, PEEP 15 cm H2O, rate 14 bpm, Fio2 1.0, a 1.5 sec inspiratory time and tidal volumes about 900 ml. ABG’s still revealed severe hypoxia PH=7.40 PaCO2=39 torr, PaO2=45 torr, HCO3=23.7 mEq, BE=-0.8 and a CXR revealed a hyperinflated left lung. It was decided to start Nitric Oxide (NO) at 20 ppm for 30minutes and to change to a Drager Evita XL Ventilator, PCV+ 25, PEEP 5 cm H2O, rate 14 bpm, Fio2 1.0, a 1.0 sec inspiratory time and tidal volumes of 400-500ml. After 30 min of NO therapy ABG’s revealed PH= 7.23 PaCO2=54 torr, PaO2=30 torr, HCO3=21.9 mEq, BE=-6.2. The NO was discontinued and the patient was then intubated with a 39 French double lumen endobronchial tube to protect the left lung and to selectively ventilate the right lung. Asynchronized ILV was initiated utilizing two Drager Evita XL ventilators. Right lung: APRV Phigh 44cmH2O/Plow 3cmH20, Thigh 6sec/Tlow .5sec Left lung: PCV+ 25, PEEP 5 cmH2O, rate 20 1.0 sec inspiratory time and tidal volumes of 400-500ml. At one hour after initiating ILV the ABG’s were PH=7.43, PaCO2=31 torr, PaO2=439 torr, HCO3=20 mEq, BE=-3.3 and the CXR revealed a hyperinflated right lung. (see figure 2)
Figure 1 CXR 1 Before ILV
Figure 2 CXR 2 After ILV
Significance of the case: Independent Lung Ventilation (ILV) appeared to be valuable in re-expanding this patient’s right lung after other interventions failed to improve the lung collapse. As a result, this patient was more effectively ventilated and oxygenated.