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,
Pa.
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.