External Stabilization of Flail Chest Using Continuous Negative Extrathoracic Pressure

External Stabilization of Flail Chest Using Continuous Negative Extrathoracic Pressure* Ralph H. Hartke, Jr., M.D.;t and A. jay Block, M.D., f~C.C.P.*

On rare occasions after total sternectomy, patients develop

persistent Hail chest deformities requiring long-term mechanical respiratory assistance. We report the use of a temporary external chest shelI to deliver constant negative extrathoracic pressure (CNEP) to a long-term ventilated patient with Hail chest. The patient's anterior thoracic cage stabilized, and significant improvement in pulmonary function was observed. With these data in hand, an operation was done to permanently stabilize the anterior chest walI by bone grafting. (Chest 1992; 102:1283-85)

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CNEP constant negative extrathoracic pressure

*From the Department of Medicine, University of Florida Colle~e of Medicine, and the Department of Veterans Affairs Medical Center, Gainesville. tInstructor and Chief Resident, Department of Medicine, University of Florida Colle~e of Medicine. *P,"?~e~sor of ~edi.cine and :\nesthesiology and Chief, Pulmonary DIvISion. Umverslty of Flonda College of Medicine. Supported by the Medical Research Service of the Department of Veterans Affairs. Reprint requests: Dr. Block, Pulmonary Medicine, JH Miller Health Center, 1600 SW Archer Road, Gainesville, FL 32610

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lail ~hest deformiti:s are t'ypically present in the immediate postoperative period followin~ total sternectomy. J Paradoxic motion of the anterior chest mav result in respiratory embarrassment. U Most of these p~tients do well, as stabilization of their chest wall occurs with ht'alin~, I.' and subsequent pulmonary function is minimally (.'ompromised.' Pectoralis muscle or omental Haps are used to repair chest wall defects. I.' On occasion, marked pamdoxic motion persists. requirin~ prolon~ed mechanical ventilation. Temporary external stabilization of Hail chest deformities has been reported to be successful in facilitatin~ weanin~ from mechanical ventilation. s We report the application of (.'onstant ne~ative extrathoracic pressure (CNEP) with a temporary external device to stabilize the anterior chest wall and improve respiratory function in a lon~-term ventilated patient with severe Hail chest. CASE REPORT

A 67-year-old man with a medical history of hypertension, diabetes mellitus, hyperlipidemia, peripheral vascular disease, and <'~)f(mary artery disease underwent aorto<'~)f(mary bypass graftin~ in Decemher 1989 for unstable anwna refmctory to medical treatment. Both his surgery and immediate postoperative murse were unremarkahle, and the patient was discharged home after one week. Four days later. the patient returned ill with purulent drainage from his sternal incision and underwent sternectomy and debridement fc,r sternal osteomyelitis and was dis<.~)Vered to have developed mediastinitis. After this, his medical course was particularly stormy, requiring prolon~ed intravenous antibiotics, mechanical ventilation,

FIGURE Ia (left). Patient is exhalin~ and no invawnation or "/Iail" of the sternal area is seeu. Ih (ri~ht). Inspiration produces pronounced inva~ination of sternal area. Arrow indicates invagination. CHEST I 102 I 4 I OCTOBER, 1992

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and subsequent tracheostomy. In February 1990, he underwent surgery for pectoralis and omental Raps to his anterior thorax. In March 1990, split-thickness skin grafting to his anterior chest was accomplished and postoperatively, he was maintained (on a Ventimask) with 50 percent oxygen. He continued to recover and during May 1990, a feeding gastrostomy tube was placed for enteral alimentation. This procedure was subsequently complicated by gastric perforation requiring emergent surgical repair. After recovery, the patient could not be weaned completely from mechanical ventilation due to the severity of his Rail chest deformity (Fig 1). He was maintained on mechanical ventilation with 35 percent oxygen, 10 cm ofwater pressure support, and six intermittent mandatory ventilations per minute for the next eight months. Due to concern that this patient would never be able to discontinue mechanical ventilation, reservations were expressed by the surgeons regarding surgical repair of his Hail chest with anterior fixation. Therefore, the patient was fitted with a customized chest shell to use CNEP to achieve temporary external stabilization of his Bail chest and effect improvement in his pulmonary mechanics. After informed, written consent was obtained, CNEP was applied at increasing increments of negative pressure using a portable negative pressure ventilator (Lifecare 17O-C Thompson, model 15001, Lifecare International, Lafayette, Colo), at 5 cm H 20 intervals varying from 0 to - 20 cm H 20. Although this cuirass type, turtle shell negative pressure ventilator is designed to apply intermittent negative pressure, the company was kind enough to modify the equipment for this specific patient. Thus, we were able to fit the chest shell, achieve a seal, and produce continuous noninterrupted negative pressure applied only to the anterior and lateral chest wall. The intention was to suck outward on the Hail sternum and stabilize it. Then the patient's spontaneous ventilation could produce a negative intrathoracic pressure without invaginating the Hail sternum. A window was placed in the turtle shell, and this sequence of events could be directly viewed and filmed. Forced vital capacity and tidal volume were measured (Wright Respirometer, Ohio Medical, Madison, Wis) at each increment of increasing negative pressure, and the patient's best efforts are recorded. Continuous oxygen saturation was monitored with a transcutaneous oximeter (Ohmeda 3700 pulse oximeter, Louisville, Colo). During all spirometry measurements, the patient was placed on room air and was monitored with a bedside telemetry unit. Initial spirometry with no applied CNEP revealed a forced vital capacity (FVC) of 300 ml, and a tidal volume (VT) of 170 ml. With

EFFECT OF CNEP*

TIDAL VOLUME AND FORCED VITAL CAPACITY ROOM AIR BY TRACH TENT

1800,...---------------.------------,

FORCED VITAL CAPACITY

1400 1200 1000 CC'S 800 800 400

- S . , I•• 1

•

FVC

- 5

- 10 eM H20 - 15

·VT

- 20

- 25

CONSTANT NEGATIVE EXTRATHORACIC PRESSURE

FIGURE 2. Vertical axis indicates the magnitude of FVC and tidal volume (VT) produced by 5 cm H 20 increments of negative pressure applied to the anterior and lateral chest wall by constant negative extrathoracic pressure (CNEP).

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The iron lung has historically used intermittent negative extrathoracic pressure to treat respiratory failure due to poliomyelitis. Modifications of this device have been developed to improve patient lifestyle by being less bulky, thereby increasing patient access and mobility.6.7 Intermittent negative extrathoracic pressure delivered to the anterior chest wall with a cuirass respirator or jacket respiratory device has been reported to be successful in ventilating patients with respiratory failure due to neuromuscular illness,7-11 kyphoscoliosis,7,1O-l.l nocturnal alveolar hypoventilation,14 chronic obstructive pulmonary disease, 15 and bilateral diaphragm paralysis. 16 CNEP is another nlodification of extrathoracic support. Successful application in patients \\'ith Pneuflwcystis carinii pneumonia 17 and adult respiratory distress syndrome l " has been reported, although administration of CN EP was delivered using an iron lung in each case. To our knowledge, our patient is the first to receive CNEP via a chest shell and the first report of the use of CNEP to stabilize the anterior chest wall in a patient with flail chest. That the CNEP did stabilize the chest \\'as evidenced by increasing VT and FVC with increasing levels of CNE~ Second, this evidence convinced the surgical service to reconstruct and stabilize permanently the anterior chest wall in this high-risk patient. The surgery was done in March 1991 and the patient was subsequently weaned from a ventilator. This report demonstrates a unique use of CNEP in a specialized situation. Flail chest can be managed with intermittent positive pressure ventilation and pressure support ventilation, and CNEP would offer no benefit to Inost patients in need of intensive care. On the other hand, if discontinuation of ventilator support is desired, CNEP may be useful in stabilizing the chest wall and in documenting the anticipated results of surgical stabilization.

REFERENCES -Seri•• 2

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0

DISCUSSION

ACKNOWLEDGMENT: The authors wish to acknowledge the aid, innovation, and effort of Ms. Peg \Varren of Lifecare International without whose help this patient could not have heen treated successfully.

TlpAL VOLU~E

200

increasin~ CNE~ si~nificant improvenlents in FVC and VT were observed (Fi~ 2). At - 20 cm of CN E~ FVC increased to 1,500 ml and VT to 775 ml. Transcutaneous oxygen saturation renlained alxlve 97 percent for all measurements of CNE~ Applil'ation of CNEP was well-tolerated, and \\,hile CNEP was applied, the patient was able to be disconnected from mechanical ventilation and was placed on room air, with continuous oxygen saturation stable at 98 percent. Subsequently, the patient undern'ent successful re<.'onstruction of his Rail chest with split rib lXlne grafting in March 1991. lie was successfully weaned from mechanical ventilation, and after successful healin~ of his chest bridge, his tracheostolny was removed three weeks postoperatively.

Adams J~ Hazard PB, Gooch JB. Flail chest injury in a patient with surgical absence of the sternum. Chest 1987; 92:1856 2 Tzelepis GE, McCool FD, Hoppin Fe; Jr. Chest wall distortion in patients \\rith Hail chest. Am Rev Respir Dis 1989; 140:31-7 3 Meadows JA, Staats BA, Pairolenro PC, Rodarte JR, Arnold PC. Effect of resection of the sternunl and manuhrium Oil conjunction with muscle transposition on pulmonary function. Mayo Clinic Proc 1985; 60:604-09 External Stabilization of Flail Chest (Hartke, Block)

4 Brown RG, Fleming WH, Juriliewicz MJ. An island Oap of the pectoralis major muscle. Br J Plastic Surg 1977; 30:161-65 5 Ali J, Hardinl B, deNiord R. Effect of temporary external stabilization on ventilator weaning after sternal resection. Chest 1989; 95:472-73 6 Hill NS. Clinical applications of body ventilations. Chest 1986; 90:897-905 7 Kinnear \v, Peich M, Taylor G, Sheenson J. Assisted ventilation using cuirass respirators. Eur Respir J 1988; 1:198-203 8 Mohr CH, Hill NS. Long term follow-up of nocturnal ventilatory assistance in patients with respiratory failure due to Duchennetype muscular dystrophy. Chest 1990; 97:91-6 9 Splainlard ML, Frates RC, Jefferson LS, Rosen CL, Harrison GM. Home negative pressure ventilation: report of 20 years of experience in patients with neuromuscular disease. Arch Phys Med Rehabill985; 66:239-41 10 Goldstein RS, Molotiv N, Skrastins R, Long S, De Rosie J, Contreras M, et aI. Reversal of sleep-induced hypoventilation and chronic respiratory failure by nocturnal negative pressure ventilation in patients with restrictive ventilatory impairment. Am Rev Respir Dis 1987; 135:1049-55 11 Gutierrez M, Beroiza T, Contreras G, Diaz 0, Cruz E, Moreno R, et aI. Weekly cuirass ventilation improves blood gases and inspiratory muscle strength in patients with chronic airOow limitation and hypereardia. Am Rev Respir Dis 1988; 138:61723 12 Fulkerson WJ, Wilkins JK, Esbenshade AM, Eskind JB, Newman JH. Life threatening hypoventilation in kyphoscoliosis: successful treatment with a molded body brace-ventilator. Am Rev Respir Dis 1984; 129:185-87 13 Kinnear \v, Hockley S, Harvey J, Shneerson J. The effects of one year of nocturnal cuirass-assisted ventilation in chest wall disease. Eur Respir J 1988; 1:204-08 14 Garay SM, Turino GM, Goldring RM. Sustained reversal of chronic hypercapnia in patients with alveolar hypoventilation syndromes. Am J Med 1981; 70;269-74 15 Cropp A, Dimarco AF. Effects of intermittent negative pressure ventilation on respiratory muscle function in patients with severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1987; 135:1056-61 16 Driver AG, Blackburn BB, Mareuard Sf, Austin EH. Bilateral diaphragm paralysis treated with cuirass ventilation. Chest 1987; 92:683-85 17 Sanyal SK, Bernal R, Hugitis WT, et aI. Continuous negative chest-wall pressure: successful use for respiratory distress in an adult. JAMA 1976; 236:1727 18 Morris AH, Elliott CG. Adult respiratory distress syndrome: successful support with continuous negative extrathoracic pressure. Crit Care Med 1985; 13:989-90

A 56-year-old man with metastatic prostatic carcinoma underwent placement of a Hickman catheter. Approximately two months after the procedure, he was admitted to the hospital with hemoptysis and in respiratory distress. A contrast computed tomographic (Cf) scan con6rmed the diagnosis of a cava-bronchial 6stula. The 6stula was surgically repaired, and the patient made a satisfactory recovery. (Chest 1992; 102:1285-86)

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ilastic central vein catheters generally have been found to be safe from complications. I Their flexibility, ease of insertion, and relative inertness have led to their popularity for long-term central venous use. Erosion of polyvinyl chloride catheters has been recognized more frequently, although still quite rare.' These generally result in a hemothorax or tamponade. Hemoptysis following erosion of a catheter into a bronchus with either type, however, is exceedingly rare. CASE REPORT

A 56-year-old man with a history of metastatic prostatic cancer had a Hickman line placed into his right superior vena cava via left subclavian approach for infusional chemotherapy with Ouoroumcil. Six weeks later, he developed a productive L'Ough and hoarseness. On examination, breath sounds were normal. Although both vocal cords moved normally, inOammation was noted. Chest roentgeno· gram showed a small right effusion with an elevated right hemidiaphragm. He was placed on a regimen of amoxicillin. Two weeks later, the patient was feeling better but had noted blood-Oecked sputum on occasion. Two days later, he presented to the emergency department with severe dyspnea. On examination, he was tachypneic and tachycardiac. Breath sounds were diminished on his right side. Chest roentgenogram showed a large effusion on his right with an elevated right hemidiaphragm. A mmputed tomographic (Cf) scan of his chest demonstmted no mediastinal or hilar adenopathy. With intravenous (IV) mntrast, the patient began coughing. Subsequent images revealed mntrast layering in his trachea (Fig 1). The patient was taken to the operating room «Ir repair of a cavabronchial 6stula. He underwent bronchos<:opy «llIowing intubation. Fresh blood was noted in his right main hnlnchus and the bronchus was occluded with clot and inOammatory debris. Following a right thoracotomy, his right lung was totally atelectatic surrounded by several hundred milliliters of serous Ouid. A 6stula was identi6ed from his superior vena cava to his right pnlximal main bronchus. This was opened, and with the catheter removed, divided and oversewn. Pericardial fat was interposed between the cava and bronchus. Rigid bronchoscopy removed the inOammatory exudate that

Unusual Cause of Hemoptysis· Hickman-Induced Cava-Bronchial Fistula 11wmas R. Winkler; M.D., F.C.C.P; Robert] Hanlin, PA.-C.;

Thomas D. Hinke, M.D.; Lowronce H. Clouse, M.D.; Michael] Krydo, M.D., F.C.C.P; and Broce N. Hathaway, M.D.

*From the Departments of Thoracic and Cardiovascular Surgery (Drs. Winkler and Hanlin), Radiology (Dr. Hinke), O~colo~ (Dr. Clouse), Pulmonary Medicine (Dr. Kryda), and Infectious Disease (Dr. Hathaway), Marsh6eld Clinic, Marsh6eld, Wis. Reprint requests: Dr: Winkler; Marshfield Clinic, Marshfield, WI 5449-5777

FIGURE 1. Computed tomographic scan with intravenous <.,mtrast at level of transverse aorta. Note contrast layering in trachea. CHEST 1102 I 4 I OCTOBER, 1992

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