A 29 year old, 80 kg male patient, known asthamatic since childhood on irreg medications, admitted to our hospital with cough, cold since 2 days, n breathlessness of 1 day duration. Patient nebulised, inf aminophylline, iv steroids given. No relief. Raised pCO2, low pO2-intubated n ventilated. Kept deeply sedated, paralysed.
Post ventilation intrinsic PEEP of 18cm H2O. pCO2 of 92mmHg. Low RR, low TV, high expiratory time ventilation. Tracheal secretions thick, purulent. Blood inv- TLC 15000. PCT<0.5. Treated with IV antibiotics (Imipenem, Linezolid, Claribid, Tamiflu) , infusion doxophylline, iv solumedrol, Nebulisation with salbutamol, Ipravent, Budecort; s/c Terbutaline.
48 hours later, persistent spasm, Intrinsic PEEP 11 cm H2O, pCO2=60 mmHg.
Please post your suggestions...
Post ventilation intrinsic PEEP of 18cm H2O. pCO2 of 92mmHg. Low RR, low TV, high expiratory time ventilation. Tracheal secretions thick, purulent. Blood inv- TLC 15000. PCT<0.5. Treated with IV antibiotics (Imipenem, Linezolid, Claribid, Tamiflu) , infusion doxophylline, iv solumedrol, Nebulisation with salbutamol, Ipravent, Budecort; s/c Terbutaline.
48 hours later, persistent spasm, Intrinsic PEEP 11 cm H2O, pCO2=60 mmHg.
Please post your suggestions...
Hi. Iv magnesium? Did u try? You can also use epinephrine infusion. If nothing is working, get an OT boyle with pressure control mode and use inhalational anesthetic agents ( iso/ sevo). Do post further course of the patient.
ReplyDeleteUsing nebs- salbutamol, budecort, Terbut, also adr nebs. Iv infusion Doxophylline, infusion ket also used, Mgsulf also been given. Also subcut adr...
ReplyDeleteUsing vol control for him as recommended in books. his initial peak pressures were 60 n plat pre= 33 with TV of just 380 n RR=14. Now Peak is 52 n Plat =30 with TV 480 n RR 14. When spasm decreases Peak decreases to 43 n plats 25 with TV 500 n RR 14.
PaCO2 came down to 50 today morn, but spasm persists (iPEEP = 5).with intermittent bad bouts n iPEEP increasing to 14.
During aggravation of spasms, pCO2 increased to 65.
i remember similar case managed in our hospital. we had to struggle for 15 days before we could even think of weaning. but fortunately we made it.
ReplyDelete1.i think we need to patiently wait till steroids take their full effect.
2.why using high tidal volume now? since he is young he will be effectively able to compensate by bicarb retention.so use low tidal volume.....i think 380 was better, if pH is more than 7.1 then u can go down the respiratory rate even upto 8-10.people have advocated a RR as low as 6 in acute exacerbation of asthma....and we have used it.
3.why giving so many antibiotics- i suppose antibiotics coverage for community org should suffice. and will not change the course.
4. infusion of doxophylline has no proven benefit. it is a even poor bronchodilator than b2 agonist.
5. have u tried propofol for sedation, we have used in our case too.
6. once iPEEP is </= 8 u can put him on pressure support.
7. pt of BT once on ventilator really do indicate bad prognosis as most of the expert say.
you could have also used an extracorporeal co2 removal device (as decap, novalung) and further reduce the tidal volume. I agree to with inhalational anesthetics sedation (not desflurane of course).
ReplyDeleteHow is the patient? Did you find any infective agent?