2011 OPEN FORUM Abstracts
A CASE STUDY: BENEFITS OF USING AIRWAY PRESSURE RELEASE VENTILATION ON PATIENTS WITH RIB FRACTURES.
Donald A. Pearman, Richard M. Ford, Garner G. Faulkner; Respiratory, UCSD Medical Center, San Diego, CA
Introduction: Airway Pressure Release Ventilation (APRV) is a mode of ventilation that provides for an elevated level of high sustained pressure that is periodically released to aid in CO2 clearance while allowing spontaneous breathing. APRV is applied with the objective to maintain lung volume resulting in improved lung mechanics, ventilation, and oxygenation due to recruitment of alveoli. The application of APRV in acute chest trauma is reported. Case Summary: A 72 year old male was admitted after being struck by a motor vehicle. The patient sustained 1 thru 8 right sided rib fractures as well as underlying hemopneumothorax and pulmonary contusion. The patient was intubated with initial ventilator settings of CMV VT 550 RR 12 and FIO2 50% with the PEEP being increased to 8 the following day due to extremely poor aeration of the right lung per chest film. Due to the decreasing lung volumes and the patient's asynchrony with the ventilator, APRV was initiated. Initial APRV settings were PEEP-High 25 PEEP-Low 0 Time-High 4.3 Time-Low .7. It was noted the patient was more synchronous with the initiation of APRV. Chest X ray post APRV initiation revealed significantly improved aeration of both lungs. Spontaneous breathing exercises on a setting of CPAP of 5 and Pressure support of 5 were started 2 days after APRV initiation. The patient was taken off the ventilator and transitioned to trach collar 14 days post APRV initiation. Discussion: Patients with multiple rib fractures have been known to develop increased atelectasis. Conventional ventilation on CMV in volume control or pressure control modes may not allow for the increased mean airway pressure needed for alveoli recruitment in conjunction with a spontaneous breathing patient. APRV is able to provide an increased mean airway pressure allowing for the recruitment and stabilization of collapsed regions with minimal sedation. Increasing mean airway pressure early in the course of the lung injury and providing the ability to spontaneously free breath, not only recruit alveoli, also requires minimal sedation. Weaning can often proceed more easily once the lung injuries have improved considering the patient was in a mode that facilitated spontaneous ventilation.
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