2011 OPEN FORUM Abstracts
USE OF AIRWAY PRESSURE RELEASE VENTILATION WITH A TRAUMATIC BRAIN INJURED PATIENT.
Brandy L. Davis, Peter Saunders, Maria Madden, Kara Vogt, Deborah M. Stein, Nader Habashi; Respiratory Care, University of Maryland Medical Center, Baltimore, MD
INTRODUCTION: Clinicians may be reluctant to use Airway Pressure Release Ventilation (APRV) when managing patients with traumatic brain injuries. There is a question that with the application of APRV, the PaCO2 cannot be successfully managed. Therefore, with an increase in PaCO2, a concomitant increase in intracranial pressures will occur. In addition, there is concern of increased intracranial pressure related to the increase in mean airway pressure with APRV. CASE SUMMARY: This case reviews a 62 year old male that was found down (presumed fall). On admission, he presented with a subdural hemorrhage and a Glasgow Coma Scale (GCS) of 7. An intraventricular catheter (IVC) was placed to monitor intracranial pressure (ICP) and drain cerebral spinal fluid. Due to a refractory increase in ICP, the patient required a craniectomy. The ventilator support was set to maintain PaCO2 between 35 and 40 cm H2O. The patient was on a Drager Evita XL with settings of SIMV/Autoflow/PS with a set respiratory rate of 25, tidal volume 550, PEEP 14, and FIO2 of 55%. On these vent settings, the patient's ICP ranged between 8-14 mmHg. The patient was then transitioned to APRV with settings of: Phigh 26, Plow 0, Thigh 4.2, Plow 0.55 (set respiratory rate of 13), FIO2 55%. Due to the improved alveolar ventilation that APRV provides, there was no need to match the SIMV minute volume (which was 13.8 L/min vs. 11.8). Analgesia and sedation remained the same with Fentanyl and precedex. In addition, hemodynamics remained stable after transition to APRV. DISCUSSION: Transitioning this patient to APRV demonstrated an improvement in oxygenation, ventilation and peak airway pressures with no untoward result of increased ICP or PaCO2. APRV has been useful as a lung recruitment mode, however, further research is needed to show the effect of APRV with TBI patients and ICPs and CO2 management.
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