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Reduction of Peak Inspiratory Pressure Using High Frequency Jet Ventilation and Pressure Control Ventilation Following Pneumonectomy
Reduction of Peak Inspiratory Pressure Using High Frequency Jet Ventilation and Pressure Control Ventilation Following Pneumonectomy* David Lain, Ph.D., R.R. T., R.C.P.; Edward F. Crocker, Jr., M.D.; Bashir A. Chaudhary, M.D., F.C .C.P.; and joseph W Rubin, M.D ., C .M., F.C.C.P.
FIGURE 2. On-line suction catheter removal resulted in reduced intrinsic PEEP and reversal of left lung herniation and mediastinal shift. After worsening of intrinsic PEEP was confirmed, our patient underwent bronchoscopy first to rule out proximal endobronchial obstruction and was then removed from the on-line suction apparatus. An immediate decrease in the intrinsic PEEP was demonstrated when the patient was intermittently removed from the ventilator for manual suctioning or for bronchoscopy. In response to this decrease in intrinsic PEEP, an improvement in the chest roentgenogram was noted. This case therefore demonstrates that intrinsic PEEP may manifest roentgenographically in patients with unequal or asymmetric lung compliance . Chest roentgenograms should be reviewed carefully for evidence of progressive hyperinflation in patients at risk for intrinsic PEEP to avert potential hemodynamic complications or barotrauma. In addition, we postulate that the unilateral hyperinflation was worsened by the application of an on-line suction apparatus to the ventilator circuit. By obviating the need for removal of the patient from the ventilator for suctioning, it eliminated intermittent release of high intrathoracic volume caused by air trapping. Periodic interruption of mechanical ventilation may thus deflate the lungs and ameliorate the effects of intrinsic PEEP. On-line suction catheters should therefore be used with caution in such patients. REFERENCES
2
3 4 5
Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow ohstmction. Am Rev Respir Dis 1982; 126:166-70 Rossi A, Gottfried SB, Zocchi L, Higgs BD, Lennox S, Calverley PMA, et al. Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation. Am Rev Respir Dis 1985; 131 :67277 Black JW, Grover BS . Ahazard of pressure support ventilation. Chest 1988; 93:333-35 Derenne JP, Fleury B, Pariente R. Acute respiratory failure of chronic obstructive pulmonary disease . Am Rev Respir Dis 1988; 138:1006-33 Carlon GC, Kahn R, Howland WS , Baron R, Ramaker J. Acute life-threatening ventilation-perfusion inequality: an indication fi>r independent lung ventilation. Crit Care Med 1978; 6:380-83
High peak inspiratory pressure (PIP) during mechanical ventilation is associated with increased risk of barotrauma. High frequency jet ventilation (HFJV) and pressure control ventilation (PCV) have been advocated for the reduction of PIP. The Food and Drug Administration has approved HFJV, respiratory frequency as high as 150 breaths per minute (bpm); however, bpm greater than 150 are still considered for experimental use. At less than 40 bpm, the point where HFJV is no longer considered to be high frequency, PCV is substituted which then becomes the mode of choice because of the ability to control ventilating pressures by setting the PIP. We present a case in which we used these two forms of ventilation for reducing the risk of stump blowout and barotrauma following pneumonectomy. (Che11t 1990; 98:229-30) PIP= peak inspiratory pressure; HFJV =high frequency jet ventilation; PCV =pressure control ventilation; CMV = conventional mechanical ventilation; VT, tidal volume
H
igh peak inspiratory pressures during conventional mechanical ventilation (CMV) are associated with increased risk of barotrauma. 1 Avoidance of barotrauma is particularly important for a patient following pneumonectomy.2 The employment of ventilatory techniques that will reduce peak inspiratory pressure (PIP) while providing adequate oxygenation and C02 elimination is helpful in certain situations. Both high frequency jet ventilation (HFJV) and pressure control ventilation (PCV) reduce PIP while maintaining oxygenation and co2 elimination. 3 ·• We describe a patient who underwent pneumonectomy for a destroyed right lung and chronic bronchopleural6stulas caused by pulmonary sporotrichosis. Both HFJV and PCV were successfully implemented to achieve a reduction in PIP. CASE REPORT
A 46-year-old man was transferred to our medical center for further evaluation following diagnosis and partial treatment for pulmonary sporotrichosis. The patient had a recent history of a 36.3-kg weight loss, shortness of breath, night sweats, fever, productive cough, and occasional hemoptysis. A chest tube had been placed to drain a pyopneumothorax purulent fluid. He had a persistent air leak. *From the Department of Respiratory Care Services, Section of Thoracic and Cardiac Surgery, Section of Pulmonary Diseases, Medical College of Georgia, Augusta. Reprint requests: Dr. Lain, Respiratory Care, BAA-928, Medical College of Georgia. Augusta 30912-5300 CHEST I 96 I 1 I JULY, 1990
229
Because of his rapidly deteriorating condition, right pneumonectomy was performed on an emergency basis. The lung was found to be contracted, nonexpansile, and densely adherent to the mediastinal and parietal pleura. The parenchyma was destroyed and multiple bronchopleural fistulas were present. Closure of the right main-stem bronchus was performed with surgical staples. The risk of stump blowout was believed to be high . Therefore, the patient was temporarily ventilated with a 39-French double lumen endotracheal tube to the left lung. This was done to avoid transferring ventilatory pressure to the bronchial stump. The patient was placed on a Siemens Servo 900C with a tidal volume (VT) of0.65 L, f- 16 breaths per minute (bpm), Flo1 of0.50, in the assist-control mode. Arterial blood gas determinations on these settings were a pH of7.42, PaC01 of53.6 mm Hg, Pa01 of 152 mm Hg, BE of 3.3, HCO, of 28.3, and Sa01 of 96.4. Initial PIP was 32 em H 10 but the third postoperative day the PIP increased to 80 to 90 em H 10. The chest roentgenogram revealed fibrosis, engorged pulmonary vasculature in the left perihilar area, and early alveolar pulmonary edema. To reduce PIP the patient was switched to HFJV using the Bear 150 jet ventilator. Initial settings were as follows: jet drive, 25 psi; rate, 50; and inspiratory time, 30 percent, with proximal airway PIP of 4 ern H10. The jet was placed proximally in the double lumen tube on the left side. Throughout jet ventilation, the pressures were monitored proximally and the PIP varied from 4 to 7 em H 10 although the distal pressures might have been higher.• On the fourth day, the double lumen endotracheal tube was removed and a tracheostomy was performed. The jet delivery was transferred to the tracheostomy tube. The patient remained on HFJV until the sixth postoperative day. The patient was switched back to conventional ventilation but the PIP was still 50 em H 20 in the assist-control mode. In order to control the high PIP, we decided to try PCV. Initially, the PIP on PCV was set to 35 em H 10 with an inspiratory:expiratory (I:E) ratio of 1:2, rate of 14, and Flo2 of 0.5. Shortly afterward, the PIP was reduced to 26 em H.O and the I:E ratio was increased to 1:3. The VT exhaled was at 0.65 L. The patient began "t-tube" trial weaning on the eighth postoperative day and was subsequently weaned from mechanical ventilation on the ninth postoperative day. He completed his course of amphotericin B and was discharged from the hospital on the fifthfirst postoperative day in good condition. DISCUSSION
In this patient with pneumonectomy, tenuous bronchial stump closure, and high PIP, we were concerned about the possibility of barotrauma-related complications. 6 •7 The use of HFJV and PCV reduced the airway pressure while maintaining adequate ventilation and oxygenation. We did not use low pressure and low VT ventilation because that may have resulted in decreased oxygenation.• Jet ventilation can provide adequate oxygenation and C02 clearance while ventilating at low PIP and low VT""'" and has been compared with and followed by CMV after cardiac and thoracic surgery. 11 "14 In patients with bronchopleural fistula, HFJV has been recognized for the reduction of PIP. During PCV, a pressure-limited time-cycled decelerating flow system for the delivery of VT is used . The I:E ratio, rate, and PIP are set and the combination of these determines the mean airway pressure and minute ventilation. Obviously, if lung compliance changes, at a set pressure , the volume delivered will vary. Pressure control ventilation can reduce PIP and provide for adequate gas exchange.<· 6 •7 In animal studies, low insufflation pressures reduced the risk of complication associated 230
with high PIP.• We believe the application of HFJV and PCV may be beneficial in selected high-risk patients undergoing lung resection. ACKNOWLEDGMENTS: Special thanks to Alfonso Graham, B.S., C.R.T.T. , Cynthia Phillip, B.S., R.R.T., and Kay McCoy for their assistance in the preparation of this manuscript. REFERENCES
1 Haake R, Schlichtry R, Ulstad DR, Henschen RR. Barotrauma. Chest 1987; 91:608-13 2 Pomerantz AH, Derasari MD, Sethi SS, Khan S. Early postpneumonectomy bronchial stump fistula. Chest 1988; 93:654-57 3 Paloski WH, Barie PS, Mullins RJ, Newell JC. Effects of changing inspiratory to expiratory time ratio on carbon dioxide elimination during high-frequency jet ventilation. Am Rev Respir Dis 1985; 131:109-14 4 Lain DC, Di Benedetto R, Morris S, Nguyen A, Saulters R, Causey D. Pressure control and inverse ratio ventilation to reduce peak inspiratory pressure and provide adequate ventilation and oxygenation. Chest 1989; 95:1081-87 5 Waterson CIC, Militzer HW, Quan SF, Calkins JM . Airway pressure as a measurement of gas exchange during highfrequency jet ventilation. Crit Care Med 1984; 12:742-46 6 Lachman B, Danzmann E , Haendly B, Johnson B. Ventilator setting and gas exchange in respiratory distress syndrome. In: Prakash 0 , ed. Applied physiology in clinical respiratory care. Dordrecht, Netherlands: Martinus Nijhoff Publishers, 1986: 15BN70-247-2662-x. 7 Hughes JMB, Hoppin FG, Mead J. Effect oflung infiltration on bronchial length and diameter in excised lungs. J Appl Physics 1972; 32:35 8 Bayly R, Sladen A, Tyler IL, Eckegury RF, Klain M, Guntupali IC. Driving pressure and arterial carbon dioxide tension during high-frequency jet ventilation in postoperative patients. Crit Care Med 1988; 26:58-61 9 Rossing TH , Slutsky AS , Lehr JL, Drinker, PA, Karnrn R, Drazen JM. Total volume and frequency dependence of carbon dioxide elimination by high-frequency ventilation. N Engl J Med 1981; 305:1375-79 10 Paloski WH. The role of convective diffusion enhancement in gas exchange during high frequency jet ventilation. PhD thesis. Troy, NY:RPI ; 1982. 11 Jenkins J, Cameron EW, Miline AC, Hunter RM . One lung anesthesia: cardiovascular and respiratory function compared during conventional ventilation and high frequency jet ventilation. Anesthesia 1987; 32:938-43 12 Normandale J, Patrick M, Sherry ICM, Feneck RO. Comparison of conventional intermittent positive pressure ventilation: studies following aortocoronary bypass graft surgery. Anesthesia 1987; 42:824-34 13 Nevin M, Van Besouw JP, William CW, Pepper JR. Acomparative study of convention versus high-frequency jet ventilation with relationship to the incidence of postoperative morbidity in thoracic surgery. Am Thoracic Surg 1987; 44:625-27 14 Sherry ICM , Windsor JP, Feneck PO. Comparison of the hemodynamic effects of intermittent positive pressure ventilation with high frequency jet ventilation: studies following valvular heart surgery. Anesthesia 1987; 42:1276-83
Reduction d Peak Inspiratory Pntssur& (L.ain et Ill)
FIGURE 2. On-line suction catheter removal resulted in reduced intrinsic PEEP and reversal of left lung herniation and mediastinal shift. After worsening of intrinsic PEEP was confirmed, our patient underwent bronchoscopy first to rule out proximal endobronchial obstruction and was then removed from the on-line suction apparatus. An immediate decrease in the intrinsic PEEP was demonstrated when the patient was intermittently removed from the ventilator for manual suctioning or for bronchoscopy. In response to this decrease in intrinsic PEEP, an improvement in the chest roentgenogram was noted. This case therefore demonstrates that intrinsic PEEP may manifest roentgenographically in patients with unequal or asymmetric lung compliance . Chest roentgenograms should be reviewed carefully for evidence of progressive hyperinflation in patients at risk for intrinsic PEEP to avert potential hemodynamic complications or barotrauma. In addition, we postulate that the unilateral hyperinflation was worsened by the application of an on-line suction apparatus to the ventilator circuit. By obviating the need for removal of the patient from the ventilator for suctioning, it eliminated intermittent release of high intrathoracic volume caused by air trapping. Periodic interruption of mechanical ventilation may thus deflate the lungs and ameliorate the effects of intrinsic PEEP. On-line suction catheters should therefore be used with caution in such patients. REFERENCES
2
3 4 5
Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow ohstmction. Am Rev Respir Dis 1982; 126:166-70 Rossi A, Gottfried SB, Zocchi L, Higgs BD, Lennox S, Calverley PMA, et al. Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation. Am Rev Respir Dis 1985; 131 :67277 Black JW, Grover BS . Ahazard of pressure support ventilation. Chest 1988; 93:333-35 Derenne JP, Fleury B, Pariente R. Acute respiratory failure of chronic obstructive pulmonary disease . Am Rev Respir Dis 1988; 138:1006-33 Carlon GC, Kahn R, Howland WS , Baron R, Ramaker J. Acute life-threatening ventilation-perfusion inequality: an indication fi>r independent lung ventilation. Crit Care Med 1978; 6:380-83
High peak inspiratory pressure (PIP) during mechanical ventilation is associated with increased risk of barotrauma. High frequency jet ventilation (HFJV) and pressure control ventilation (PCV) have been advocated for the reduction of PIP. The Food and Drug Administration has approved HFJV, respiratory frequency as high as 150 breaths per minute (bpm); however, bpm greater than 150 are still considered for experimental use. At less than 40 bpm, the point where HFJV is no longer considered to be high frequency, PCV is substituted which then becomes the mode of choice because of the ability to control ventilating pressures by setting the PIP. We present a case in which we used these two forms of ventilation for reducing the risk of stump blowout and barotrauma following pneumonectomy. (Che11t 1990; 98:229-30) PIP= peak inspiratory pressure; HFJV =high frequency jet ventilation; PCV =pressure control ventilation; CMV = conventional mechanical ventilation; VT, tidal volume
H
igh peak inspiratory pressures during conventional mechanical ventilation (CMV) are associated with increased risk of barotrauma. 1 Avoidance of barotrauma is particularly important for a patient following pneumonectomy.2 The employment of ventilatory techniques that will reduce peak inspiratory pressure (PIP) while providing adequate oxygenation and C02 elimination is helpful in certain situations. Both high frequency jet ventilation (HFJV) and pressure control ventilation (PCV) reduce PIP while maintaining oxygenation and co2 elimination. 3 ·• We describe a patient who underwent pneumonectomy for a destroyed right lung and chronic bronchopleural6stulas caused by pulmonary sporotrichosis. Both HFJV and PCV were successfully implemented to achieve a reduction in PIP. CASE REPORT
A 46-year-old man was transferred to our medical center for further evaluation following diagnosis and partial treatment for pulmonary sporotrichosis. The patient had a recent history of a 36.3-kg weight loss, shortness of breath, night sweats, fever, productive cough, and occasional hemoptysis. A chest tube had been placed to drain a pyopneumothorax purulent fluid. He had a persistent air leak. *From the Department of Respiratory Care Services, Section of Thoracic and Cardiac Surgery, Section of Pulmonary Diseases, Medical College of Georgia, Augusta. Reprint requests: Dr. Lain, Respiratory Care, BAA-928, Medical College of Georgia. Augusta 30912-5300 CHEST I 96 I 1 I JULY, 1990
229
Because of his rapidly deteriorating condition, right pneumonectomy was performed on an emergency basis. The lung was found to be contracted, nonexpansile, and densely adherent to the mediastinal and parietal pleura. The parenchyma was destroyed and multiple bronchopleural fistulas were present. Closure of the right main-stem bronchus was performed with surgical staples. The risk of stump blowout was believed to be high . Therefore, the patient was temporarily ventilated with a 39-French double lumen endotracheal tube to the left lung. This was done to avoid transferring ventilatory pressure to the bronchial stump. The patient was placed on a Siemens Servo 900C with a tidal volume (VT) of0.65 L, f- 16 breaths per minute (bpm), Flo1 of0.50, in the assist-control mode. Arterial blood gas determinations on these settings were a pH of7.42, PaC01 of53.6 mm Hg, Pa01 of 152 mm Hg, BE of 3.3, HCO, of 28.3, and Sa01 of 96.4. Initial PIP was 32 em H 10 but the third postoperative day the PIP increased to 80 to 90 em H 10. The chest roentgenogram revealed fibrosis, engorged pulmonary vasculature in the left perihilar area, and early alveolar pulmonary edema. To reduce PIP the patient was switched to HFJV using the Bear 150 jet ventilator. Initial settings were as follows: jet drive, 25 psi; rate, 50; and inspiratory time, 30 percent, with proximal airway PIP of 4 ern H10. The jet was placed proximally in the double lumen tube on the left side. Throughout jet ventilation, the pressures were monitored proximally and the PIP varied from 4 to 7 em H 10 although the distal pressures might have been higher.• On the fourth day, the double lumen endotracheal tube was removed and a tracheostomy was performed. The jet delivery was transferred to the tracheostomy tube. The patient remained on HFJV until the sixth postoperative day. The patient was switched back to conventional ventilation but the PIP was still 50 em H 20 in the assist-control mode. In order to control the high PIP, we decided to try PCV. Initially, the PIP on PCV was set to 35 em H 10 with an inspiratory:expiratory (I:E) ratio of 1:2, rate of 14, and Flo2 of 0.5. Shortly afterward, the PIP was reduced to 26 em H.O and the I:E ratio was increased to 1:3. The VT exhaled was at 0.65 L. The patient began "t-tube" trial weaning on the eighth postoperative day and was subsequently weaned from mechanical ventilation on the ninth postoperative day. He completed his course of amphotericin B and was discharged from the hospital on the fifthfirst postoperative day in good condition. DISCUSSION
In this patient with pneumonectomy, tenuous bronchial stump closure, and high PIP, we were concerned about the possibility of barotrauma-related complications. 6 •7 The use of HFJV and PCV reduced the airway pressure while maintaining adequate ventilation and oxygenation. We did not use low pressure and low VT ventilation because that may have resulted in decreased oxygenation.• Jet ventilation can provide adequate oxygenation and C02 clearance while ventilating at low PIP and low VT""'" and has been compared with and followed by CMV after cardiac and thoracic surgery. 11 "14 In patients with bronchopleural fistula, HFJV has been recognized for the reduction of PIP. During PCV, a pressure-limited time-cycled decelerating flow system for the delivery of VT is used . The I:E ratio, rate, and PIP are set and the combination of these determines the mean airway pressure and minute ventilation. Obviously, if lung compliance changes, at a set pressure , the volume delivered will vary. Pressure control ventilation can reduce PIP and provide for adequate gas exchange.<· 6 •7 In animal studies, low insufflation pressures reduced the risk of complication associated 230
with high PIP.• We believe the application of HFJV and PCV may be beneficial in selected high-risk patients undergoing lung resection. ACKNOWLEDGMENTS: Special thanks to Alfonso Graham, B.S., C.R.T.T. , Cynthia Phillip, B.S., R.R.T., and Kay McCoy for their assistance in the preparation of this manuscript. REFERENCES
1 Haake R, Schlichtry R, Ulstad DR, Henschen RR. Barotrauma. Chest 1987; 91:608-13 2 Pomerantz AH, Derasari MD, Sethi SS, Khan S. Early postpneumonectomy bronchial stump fistula. Chest 1988; 93:654-57 3 Paloski WH, Barie PS, Mullins RJ, Newell JC. Effects of changing inspiratory to expiratory time ratio on carbon dioxide elimination during high-frequency jet ventilation. Am Rev Respir Dis 1985; 131:109-14 4 Lain DC, Di Benedetto R, Morris S, Nguyen A, Saulters R, Causey D. Pressure control and inverse ratio ventilation to reduce peak inspiratory pressure and provide adequate ventilation and oxygenation. Chest 1989; 95:1081-87 5 Waterson CIC, Militzer HW, Quan SF, Calkins JM . Airway pressure as a measurement of gas exchange during highfrequency jet ventilation. Crit Care Med 1984; 12:742-46 6 Lachman B, Danzmann E , Haendly B, Johnson B. Ventilator setting and gas exchange in respiratory distress syndrome. In: Prakash 0 , ed. Applied physiology in clinical respiratory care. Dordrecht, Netherlands: Martinus Nijhoff Publishers, 1986: 15BN70-247-2662-x. 7 Hughes JMB, Hoppin FG, Mead J. Effect oflung infiltration on bronchial length and diameter in excised lungs. J Appl Physics 1972; 32:35 8 Bayly R, Sladen A, Tyler IL, Eckegury RF, Klain M, Guntupali IC. Driving pressure and arterial carbon dioxide tension during high-frequency jet ventilation in postoperative patients. Crit Care Med 1988; 26:58-61 9 Rossing TH , Slutsky AS , Lehr JL, Drinker, PA, Karnrn R, Drazen JM. Total volume and frequency dependence of carbon dioxide elimination by high-frequency ventilation. N Engl J Med 1981; 305:1375-79 10 Paloski WH. The role of convective diffusion enhancement in gas exchange during high frequency jet ventilation. PhD thesis. Troy, NY:RPI ; 1982. 11 Jenkins J, Cameron EW, Miline AC, Hunter RM . One lung anesthesia: cardiovascular and respiratory function compared during conventional ventilation and high frequency jet ventilation. Anesthesia 1987; 32:938-43 12 Normandale J, Patrick M, Sherry ICM, Feneck RO. Comparison of conventional intermittent positive pressure ventilation: studies following aortocoronary bypass graft surgery. Anesthesia 1987; 42:824-34 13 Nevin M, Van Besouw JP, William CW, Pepper JR. Acomparative study of convention versus high-frequency jet ventilation with relationship to the incidence of postoperative morbidity in thoracic surgery. Am Thoracic Surg 1987; 44:625-27 14 Sherry ICM , Windsor JP, Feneck PO. Comparison of the hemodynamic effects of intermittent positive pressure ventilation with high frequency jet ventilation: studies following valvular heart surgery. Anesthesia 1987; 42:1276-83
Reduction d Peak Inspiratory Pntssur& (L.ain et Ill)