2012 OPEN FORUM Abstracts
PERFORATION OF THE RIGHT TYMPANIC MEMBRANE SEEN IN A PATIENT WITH DUCHENNE MUSCULAR DYSTROPHY USING A MECHANICAL ASSIST COUGH DEVICE AND NON-INVASIVE VENTILATION.
Scott Gee1, Gary R. Lowe1, Robert H. Warren2; 1Respiratory Care Services, Arkansas Childrens Hospital, Little Rock, AR; 2Dept. of Pediatrics, Pulmonary Medicine Section, University of Arkansas for Medical Sciences, Little Rock, AR
Introduction: Patients with Duchenne muscular dystrophy (DMD) frequently utilize positive pressure devices to maintain adequate bronchial hygiene and ventilation due to the progressive muscle weakness they experience. While these devices can greatly improve their quality of life, they can also present some unexpected challenges. This case illustrates the course of a 19 year old male with DMD who presented with a perforated right tympanic membrane (TM) following the use of these devices. Case Summary: During a clinic visit, the patient reported while using a mechanical assist cough (MAC) device at 35 cmH2O, he experienced a loud pop in his right ear. He also reported when using non-invasive ventilation (NIV) at night, he experienced a dull pain in his right ear, and noise that kept him awake. He was placed on NIV for assessment, and it was noted that air was flowing through his right ear, creating a whistling sound and causing the TM to flutter. Pressure Control (PC) on NIV was lowered from 20 to 16 cmH2O until he became asymptomatic of ear problems. MAC pressures were also lowered to a maximal setting of 30 cmH2O. The patient had a pressure equalization (PE) tube present which should have served as a pressure relief device to prevent TM perforation, which did not occur. He was referred to ENT and the PE tube was removed to allow the TM to heal. Even with the reduction of pressures with NIV and MAC, the TM did not heal. Approximately 13 months after the initial report of TM perforation, ENT confirmed it had finally healed and the patient should be able to tolerate higher pressures. During this time, the patient had been mostly non-compliant with therapy, and experienced an increase in pCO2 levels from 48 to 65 mmHg. One month later, the patient collapsed, was non-responsive, and had no pulse or respirations. He was successfully resuscitated. As a result of this experience, the patients compliance with NIV and MAC improved. Pressures were increased on both devices in an attempt to improve his ventilatory status by normalizing his pCO2 levels. Discussion: Perforation of the TM while utilizing positive pressure devices is a rarely reported event. To validate the patients complaint, placing him on NIV during a clinic visit and observing the air leak was extremely important in taking measures to minimize the problem. The challenge in this case was balancing the reduction of pressures while maintaining adequate ventilation, and allowing the TM to heal. Sponsored Research - None