2006 OPEN FORUM Abstracts
A CASE STUDY: ESOPHAGEAL PRESSURE MONITOR USED TO ASSIST MEDICATION MANAGEMENT AND FACILITATE EXTUBATION
Raymond Wolff Jr., RRT, George Lopez MD, Chris Barnett BS, RRT, Marilyn Travis
BS, RRT,
Margaret Berger RRT, Ken D Hargett
BS, RRT.
The
Introduction: Neuromuscular
disease delivers an exceptional patient population where the RSBI may not be a
reliable indicator for readiness to extubate.
We have found that with the application of esophageal pressure
monitoring, we are able to identify a patient's readiness to extubate more
accurately and potentially reduce the incidence of failed extubation, defined
as a reintubation within 24 hrs of extubation.
Through measurement of the esophageal pressure changes (Delta Pes)
we are able to identify changes in a patient's inspiratory effort throughout
the day that prevented extubation and with the trend information to facilitate
medication administration changes that resulted in successful extubation
Case Summary:
Patient is a 22 year old male.
Patient began to experience increase in cough with white nasal drainage. The patient also presented with dysphasia,
dysarthria and diplopia. Patient was
admitted for exacerbation of myasthenia gravis.
Patient was eventually intubated and ventilated via the Viasys AVEA
ventilator. Patient was treated with
Mestinon and intravenous gamma globulin for the muscle weakness. Patient status improved and RSBI, MIP, and
Vital Capacity were all measured per our standard practice to gauge patients
readiness to extubate. Parameters were acceptable
and patient was extubated. Patient was
reintubated soon after for respiratory failure.
Subsequent attempts to determine extubation readiness with standard
parameters resulted in borderline measurements. An esophageal balloon was
inserted to measure Delta Pes.
This allowed us the opportunity to measure and trend patient efforts
over a 24hr period. It was discovered
that in the early morning the patient was the weakest with Delta Pes
measuring 1-4 cmH2O. As the
day progressed the Delta Pes would increase to 12-25 cmH2O. Normal Delta Pes measures
15-25cmH2O.After tedious review of his chart we identified why the phenomenon
was occurring. We recognized that the
scheduling and synchrony of pain medication and the Mestinon was the factors
limiting his muscle strength and preventing ventilator liberation. Simple changes to the scheduling of these two
medications lead to a direct improvement in patient strength. After the medication schedule change the
standard parameters continued to result in borderline measurements and were the
same as pre medication changes.
Nevertheless the Delta Pes increased to 18-26 cmH2O
in the early morning and maintained similar Delta Pes through out
the day, the lowest being an average of 15 cmH2O at 7:00 AM. Based on the Esophageal monitor, the patient
was extubated one day after the change in the medication schedule and without
complications. The patient was
discharged from the hospital within a week.
Discussion: Our staff is
encouraged and taught to utilize all resources and to maximize a ventilators
capability to facilitate liberation safely and quickly. Identifying readiness to extubate by
performing daily spontaneous breathing trials is part of our standard of care. Until recently the RSBI, from the daily
spontaneous breathing trial, was our primary measurement to determine readiness
to extubate. We have learned that with
neuromuscular disease the RSBI may not be as reliable as with patients without
neuromuscular disease. The Delta Pes
on the Viasys Avea gives us the ability to not only monitor patient and vent
synchrony but to measure and trend inspiratory efforts over 24 hour time
periods. The Delta Pes also gives
us the additional information to identify patients who may generate adequate RSBI
but do not have the muscle strength to support prolonged spontaneous
ventilation and avoid reintubation. Expanded use of Espohogeal Pressure
Monitoring in difficult to wean ventilator patients is a useful tool in
determining readiness to extubate.