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Is Prone Positioning Effective for Atelectasis in Non-ARDS Patients?
Critical Care SESSION TITLE: Fellow Case Report Poster - Critical Care I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Is Prone Positioning Effective for Atelectasis in Non-ARDS Patients? Erik Vakil MD*; and Kamran Boka MD University of Texas Health Sciences Center, Houston, TX INTRODUCTION: Prone positioning (PP) is a proven intervention for refractory hypoxemia in patients with the acute respiratory distress syndrome (ARDS). Less is known about the efficacy of PP for hypoxic respiratory failure (HRF) of other etiologies. Our case demonstrates the potential benefit of PP in HRF caused by severe atelectasis without evidence of inflammation or edema. CASE PRESENTATION: A 46 year-old male presented to an affiliate hospital with fever, back pain, dyspnea and altered mentation. He was intubated for HRF and transferred to our facility for tertiary level care. Chest computed tomography (CT) without contrast revealed bi-basilar atelectasis without air bronchograms or ground glass attenuation. Vertebral lytic lesions were noted and lab findings were characteristic for multiple myeloma. Respiratory cultures were negative and persistent fevers were attributed to malignancy. Atelectasis was attributed to severe lumbago and hypoventilation from altered mentation. PEEP-based lung recruitment maneuvers and intrapulmonary percussive ventilation were used with limited success to improve oxyenation. Daily spontaneous breathing trials were complicated by severe back pain requiring high dose opiate analgesia. On hospital day 8, the patient was placed in PP using the RotaProne system. Oxygenation improved after 3 days (Table 1) and repeat CT substantiated improvement in atelectasis (Figure 1). The patient was extubated after an additional 72 hours in the supine position. He was discharged home hospital day 26.
CRITICAL CARE
DISCUSSION: A proportion of patients with ARDS develop marked basilar atelectasis causing hypoxemia from V/Q mismatch and increased dead space ventilation. Mechanical ventilation leads to alveolar over-distention of remaining aerated lung and is associated with ventilator-associated lung injury. Prone positioning has been shown to recruit lung in dependent areas and reverse over-inflation of ventral areas. Our case describes HRF not clearly associated with lung inflammation or pulmonary edema in which PP was used to recruit atelectatic lung refractory to other modalities. Significant improvement in oxygenation, ventilator mechanics and radiographic findings was achieved after 72 hours. Our case suggests that PP may be applied to cases of refractory atelectasis without ARDS to improve oxygenation and expedite extubation. CONCLUSIONS: Prone positioning may improve oxygenation and expedite extubation in patients with HRF caused by atelectasis without ARDS. Reference #1: Guérin et. al. NEJM 2013;368:2159 DISCLOSURE: The following authors have nothing to disclose: Erik Vakil, Kamran Boka No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.247
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
234A
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150#4S CHEST OCTOBER 2016
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Is Prone Positioning Effective for Atelectasis in Non-ARDS Patients? Erik Vakil MD*; and Kamran Boka MD University of Texas Health Sciences Center, Houston, TX INTRODUCTION: Prone positioning (PP) is a proven intervention for refractory hypoxemia in patients with the acute respiratory distress syndrome (ARDS). Less is known about the efficacy of PP for hypoxic respiratory failure (HRF) of other etiologies. Our case demonstrates the potential benefit of PP in HRF caused by severe atelectasis without evidence of inflammation or edema. CASE PRESENTATION: A 46 year-old male presented to an affiliate hospital with fever, back pain, dyspnea and altered mentation. He was intubated for HRF and transferred to our facility for tertiary level care. Chest computed tomography (CT) without contrast revealed bi-basilar atelectasis without air bronchograms or ground glass attenuation. Vertebral lytic lesions were noted and lab findings were characteristic for multiple myeloma. Respiratory cultures were negative and persistent fevers were attributed to malignancy. Atelectasis was attributed to severe lumbago and hypoventilation from altered mentation. PEEP-based lung recruitment maneuvers and intrapulmonary percussive ventilation were used with limited success to improve oxyenation. Daily spontaneous breathing trials were complicated by severe back pain requiring high dose opiate analgesia. On hospital day 8, the patient was placed in PP using the RotaProne system. Oxygenation improved after 3 days (Table 1) and repeat CT substantiated improvement in atelectasis (Figure 1). The patient was extubated after an additional 72 hours in the supine position. He was discharged home hospital day 26.
CRITICAL CARE
DISCUSSION: A proportion of patients with ARDS develop marked basilar atelectasis causing hypoxemia from V/Q mismatch and increased dead space ventilation. Mechanical ventilation leads to alveolar over-distention of remaining aerated lung and is associated with ventilator-associated lung injury. Prone positioning has been shown to recruit lung in dependent areas and reverse over-inflation of ventral areas. Our case describes HRF not clearly associated with lung inflammation or pulmonary edema in which PP was used to recruit atelectatic lung refractory to other modalities. Significant improvement in oxygenation, ventilator mechanics and radiographic findings was achieved after 72 hours. Our case suggests that PP may be applied to cases of refractory atelectasis without ARDS to improve oxygenation and expedite extubation. CONCLUSIONS: Prone positioning may improve oxygenation and expedite extubation in patients with HRF caused by atelectasis without ARDS. Reference #1: Guérin et. al. NEJM 2013;368:2159 DISCLOSURE: The following authors have nothing to disclose: Erik Vakil, Kamran Boka No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.247
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
234A
[
150#4S CHEST OCTOBER 2016
]