2005 OPEN FORUM Abstracts
THE USE OF ALVEOLAR RECRUITMENT MANEUVERS COMBINED WITH INTRAPULMONARY PERCUSSIVE VENTILATION IN A PATIENT WITH NEUROMUSCULAR DISEASE TO IMPROVE ALVEOLAR STABILITY AND ARTERIAL OXYGENATION. Raymond Wolff Jr., RRT, RCP, Evelyn Shearer-Poor MD, FCCP, George Brown, RRT, Kimberly Randle, CRT, Brian Timon BS, RRT, Ken Hargett BS, RRT, The Methodist Hospital, Respiratory Care Department, Houston, TX.
Introduction: Ventilatory failure is common in the patient with neurological and / or neuromuscular disease that weakens the respiratory muscles. We have observed patients with neurological and / or neuromuscular diseases experience problems with secretion clearance, Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS) secondary to cardiogenic and / or neurogenic pulmonary edema. In the past, we have had great success in secretion removal with the use of Intrapulmonary Percussive Ventilation (IPV). We have also experienced success with conventional and modified recruitment maneuvers to promote alveolar stability.
Case Summary: Patient is a 31-year-old white male who was admitted to the Neuro- Intensive Care Unit for muscle weakness, later diagnosed as Guillain-Barre' Syndrome. He served in Desert Storm where he was exposed to high levels of uranium. His most recent job has been a security guard for a local chemical plant. Prior to this admission he had been diagnosed with asthma and fibrotic lung disease. Five days after admission, the patient went into Acute Respiratory Failure and was diagnosed with pneumococcal sepsis and pneumonia. The patient was intubated, developed a pneumothorax with subcutaneous air and required a chest tube via thoracotomy. The patient was sedated for comfort and large amounts of thick white secretions required frequent suctioning. The patient was ventilated with the Puritan Bennett 840 ventilator. Initial ventilator settings were Volume/Control Plus (VC+)-SIMV rate 12, tidal volume 600ml, PEEP 12cmH2O FiO2 1.0. The required Inspiratory Pressure (IP) varied between 43-45cmH2O. PEEP was increased to 17cmH2O based on the lower inflection from a slow flow pressure volume loop. The patient's ABG was as follows: pH-7.31 / PaCO2-53 / PaO2-42. Pressure Control and Bi-Level ventilation did not prove to be advantageous. The patient became more hemodynamically unstable and the SpO2 decreased to 77%. Prone positioning was discussed but not implemented due to the patient's unstable hemodynamics. The PEEP was reduced to 15cmH2O in an attempt to decrease potential pulmonary capillary compression and or a cardiac tamponade effect. The SpO2 increased to 80%. Next, a modified alveolar recruitment maneuver was applied. The maneuver consisted of placing the patient on spontaneous ventilation without pressure support and the PEEP was set to equal the plateau pressure. The maneuver was held for forty seconds, and the patient was returned to his previous settings. The maneuver was then followed by intrapulmonary percussive ventilation (IPV) therapy. Within ten minutes after the initial alveolar recruitment maneuver the patient's saturation increased from 80% to 85% and the patient's PaO2 increased from 42mmHg to 50mmHg. The recruitment maneuver was repeated every 4 hours with continued improvement in PaO2, SpO2, and a decrease in Inspiratory Pressure. IPV was administered after each recruitment maneuver providing significant secretion clearance resulting in further improvement in SpO2, and a decrease in IP. Eight hours post implementation of therapy, the ABG improved to pH-7.31 / PaC02-52 / PaO2-78 and IP decreased to 33-35 cmH2O. Patient status continued to improve. Patient was liberated from the ventilator within 10 days.
Discussion: Recruiting alveoli, maintaining lung volume stability, and secretion clearance with the use of recruitment maneuvers, PEEP, and IPV to prevent repetitive alveolar collapse and expansion (RACE) is one of our primary goals. Many patients may not respond to a single therapy approach. We have found that a combination of conventional and modified recruitment therapies combined with appropriate PEEP and IPV have given us success with lung preservation and ventilation.