The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

THE CHOICE OF MECHACNIAL VENTILATION IN KIDNEY TRANSPLANT RECIPINTS WITH SEVERE RESPIRATORY FAILURE CAUSED BY PULMONARY INFECTION: INVASIVE OR NONINVASIVE?

Y. Q. Zhan1, H. P. Dai1, J. Li1, K. W. Huang1, Z. J. Luo1, C. Wang1


[Background]
Associated with various types of immunosuppressant, transplant recipients remain at high risk for developing a myriad of serious and often life-threatening complications, paramount among which are pulmonary complications, especially on 1 to 6 months after transplantation1. Conventionally, patients in whom respiratory failure develop often require invasive mechanical ventilation (IMV) via endotracheal intubation (ETI). Unfortunately, IMV in immunosuppressed patients is associated with a high expected mortality which surpasses 70%2-5. In the past two years, 11 consecutive patients who had been infected and complicated with severe respiratory failure after kidney transplantation were admitted to our RICU, all of them survived.

[Methods]

The clinical data included demographic information, final diagnosis, ventilation setting and monitoring parameters, duration on the ventilator, vital signs and blood gas analysis at 1 hour before ventilation, after 2-4,12, 24 hours and 2,3,5,7 days, as well as the time when the patients discharged from ICU, outcome and ICU stay. 1 hour before NPPV was defined as baseline.

[Results]
All the patients who discharged from hospital in good condition all used NPPV primarily and responded to NPPV within the first 24 hours. PaO2/FiO2 increased from 102±43 to 154±70 mmHg 2-4 hours after NPPV (P<0.05), continued rising to 159±58 mmHg (P<0.01) 24 hours later. 3 of them switched to IMV as they failed NPPV and NPPV was subsequently used to facilitate early weaning from IMV 4-6 days later. The remaining 8 patients successfully received NPPV, 3 of whom were intubated temporally for the purpose of getting pathogen evidence through bronchoalveolar lavage and continued NPPV immediately after extubation. Bronchoscopy findings established specific microbiologic diagnosis in 5 of 6 intubated patients, whose ICU stay was remarkably shorter than the other 6 patients without receiving bronchoscopy (12.6±5.4 days vs 24.0±19.3 days).

[Conclusions]
For kidney transplant recipients with severe respiratory failure induced by pulmonary infection, the initiation of NPPV is associated with significant reduction of endotracheal intubation. IMV is an effective life-saving treatment for the patients who fail NPPV and ensures the safe use of bronchoscopy to identify the infectious pathogen. As used for facilitating early weaning, NPPV shortens the duration on IMV.

characteristics of the patients on baseline and discharging from RICU
  Baseline Discharging from RICU P
No. of case 11 11 -
Body temperature 37.6±1.1 36.6±0.4 0.011
Heart rate, beats/min 116±17 89±13 0.001
Mean arterial pressure, mmHg 97±16 85±9 0.006
Respiratory rate, breaths/min 38±922±5 0.000
Glasgow coma score 15 15 -
SpO2,% 85±9 96±2 0.002
Arterial pH 7.44±0.07 7.40±0.03 0.137
PaCO2, mmHg 32±5 36±5 0.017
PaO2/FiO2, mmHg 102±43 248±41 0.000
White blood cells, 109/L 9.58±3.67 7.72±3.96 0.228
Neutrophil, % 89±9 74±10 0.001
BUN, mg/dL 29.5±11.8 34.1±9.1 0.263
Crea, mg/dL 1.6±0.6 1.8±1.6 0.005
APACHE II 15±6 7±4 0.000



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