The Science Journal of the American Association for Respiratory Care

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 Methodist Hospital, Respiratory Care Services, Houston, TX

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.

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