Differential ventilation with low-flow CPAP and CPPV in the treatment of unilateral chest trauma

Independent Lung Ventilation in a Pediatric Patient with a Firearm Injury

Background: Chest trauma is uncommon in pediatric patients, however, it may be a cause of significant morbidity and mortality. The type and extent of the injury may lead to ventilation and perfusion problems, therefore, there may be a need for mechanical ventilation. Conclusions: "Independent lung ventilation" may be an appropriate option in selected cases in which the aim is to protect the healthy lung or ventilation cannot be obtained with known mechanical ventilation methods. Case: We presented a pediatric patient followed up in the intensive care unit because of a firearm injury, in whom left lung expansion could not be obtained despite repeated interventions, and independent lung ventilation resulted in success.

Positive pressure ventilation in a patient with a right upper lobar bronchocutaneous fistula: right upper bronchus occlusion using the cuff of a left-sided double lumen endobronchial tube

In patients with a bronchocutaneous fistula, positive pressure ventilation leads to air leakage and potential hypoxemia. A male patient with a right upper bronchocutaneous fistula was scheduled for esophageal reconstruction. His preoperative chest computed tomography image revealed aeration in the right middle and lower lobe, a large bulla in the left upper lobe, and pleural effusion and pneumonia in the left lower lobe. Therefore, left one-lung ventilation was considered to result in hypoxemia. Before anesthesia induction, the bronchocutaneous fistula was covered with gauze and film to prevent air leakage. After anesthesia induction, mask ventilation was performed with a peak positive pressure of 10 cmH₂O. A left-sided double lumen endobronchial tube (DLT) was then inserted into the right main bronchus for occluding only the right superior bronchus, and two-lung ventilation was performed to minimize airway pressure and maintain oxygenation, which did not cause air leakage through the fistula. During anesthesia, no ventilation-related difficulty was faced. The method of inserting a left-sided DLT into the right main bronchus and occluding the right upper bronchus selectively by bronchial cuff is considered to be an option for mechanical ventilation in patients with a right upper bronchial fistula, as demonstrated in the present case.

Independent lung ventilation in the management of ARDS and bronchopleural fistula

Independent lung ventilation is a decades-old, but infrequently used technique for physiological separation in critically-ill patients with asymmetric lung disease. Here we present a case report of bilateral necrotizing pneumonia complicated by acute respiratory distress syndrome and bronchopleural fistula, which was successfully managed with independent lung ventilation. The use of independent lung ventilation allowed for adequate oxygenation with use of high positive end expiratory pressure in the "good lung" while simultaneously allowing for closure of the bronchopulmonary fistula in the contralateral lung by maintaining relatively low airway pressures.

Management of pulmonary contusion and flail chest: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Despite the prevalence and recognized association of pulmonary contusion and flail chest (PC-FC) as a combined, complex injury pattern with interrelated pathophysiology, the mortality and morbidity of this entity have not improved during the last three decades. The purpose of this updated EAST practice management guideline was to present evidence-based recommendations for the treatment of PC-FC.

METHODS

A query was conducted of MEDLINE, Embase, PubMed and Cochrane databases for the period from January 1966 through June 30, 2011. All evidence was reviewed and graded by two members of the guideline committee. Guideline formulation was performed by committee consensus.

RESULTS

Of the 215 articles identified in the search, 129 were deemed appropriate for review, grading, and inclusion in the guideline. This practice management guideline has a total of six Level 2 and eight Level 3 recommendations.

CONCLUSION

Patients with PC-FC should not be excessively fluid restricted but should be resuscitated to maintain signs of adequate tissue perfusion. Obligatory mechanical ventilation in the absence of respiratory failure should be avoided. The use of optimal analgesia and aggressive chest physiotherapy should be applied to minimize the likelihood of respiratory failure. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury. Paravertebral analgesia may be equivalent to epidural analgesia and may be appropriate in certain situations when epidural is contraindicated.A trial of mask continuous positive airway pressure should be considered in alert patients with marginal respiratory status. Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. Positive end-expiratory pressure or continuous positive airway pressure should be provided. High-frequency oscillatory ventilation should be considered for patients failing conventional ventilatory modes. Independent lung ventilation may also be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected.Surgical fixation of flail chest may be considered in cases of severe flail chest failing to wean from the ventilator or when thoracotomy is required for other reasons. Self-activating multidisciplinary protocols for the treatment of chest wall injuries may improve outcome and should be considered where feasible.Steroids should not be used in the therapy of pulmonary contusion. Diuretics may be used in the setting of hydrostatic fluid overload in hemodynamically stable patients or in the setting of known concurrent congestive heart failure.

Mechanical ventilation strategies in massive chest trauma

Patients in extremis because of trauma-related massive chest injury require expedient evaluation and prompt intervention. The initial pathophysiology relates to the significant intrapulmonary shunting caused by disruption of pulmonary capillaries and extravasation into the alveolar spaces. Disproportionate or unilateral lung involvement needs measures more technical than general supportive care. Independent lung ventilation (mostly with unilateral lung involvement) and other strategies like inhaled nitric oxide, prone positioning, partial liquid ventilation, and extracorporeal membrane oxygenation (ECMO) have had good results. Intensivists confronted with this clinical subset may consider using these strategies as alternative/adjunctive options for optimizing respiratory and hemodynamic status in the supportive management of trauma-related acute lung injury (ALI) and adult respiratory distress syndrome (ARDS).

Clinical review: Independent lung ventilation in critical care

Independent lung ventilation (ILV) can be classified into anatomical and physiological lung separation. It requires either endobronchial blockade or double-lumen endotracheal tube intubation. Endobronchial blockade or selective double-lumen tube ventilation may necessitate temporary one lung ventilation. Anatomical lung separation isolates a diseased lung from contaminating the non-diseased lung. Physiological lung separation ventilates each lung as an independent unit. There are some clear indications for ILV as a primary intervention and as a rescue ventilator strategy in both anatomical and physiological lung separation. Potential pitfalls are related to establishing and maintaining lung isolation. Nevertheless, ILV can be used in the intensive care setting safely with a good understanding of its limitations and potential complications.

Venilator Management and Criical Care Issues Following Cardiothoracic Trauma

Traumatic injury of the cardiac, pulmonary, or vascular systemsmay result in severe critical illness. Not only does the injury itself result in compromise of normal physiology, but initiation of the inflammatory cascade and mismanagement of the ventilator may lead to worsening status, the acute respiratory distress syndrome, and multiple organ dysfunction. Traumatic injury places the patient athigh risk of infection and nutritional compromise. We review basic concepts of mechanical ventilation and ventilator -associated or -induced lung injury. Barotrauma, volutrauma, atelectrauma and biotrauma, and methods for the clinician to prevent them, arediscussed. Airway pressure release ventilation, mandatory minute ventilation and adaptive support ventilation techniques are intro-duced, as is a discussion of the importance of spontaneous breathing during mechanical ventilation. Special attention is paid to a comprehensive approach to respiratory care. Unique modalities such as prone positioning, independent lung ventilation, and extracorporeal support are presented. The importance of adapting the mode or the minimal-injury concepts of mechanical ventilation to specific injuries is presented. Management approaches to these injuries, including ventilator therapy, pain control, surgical techniques, and critical care issues are described. An overview of the issues of infection inherent to trauma, and nutritional matters, including enteral versus parenteral therapy is presented. Immune-enhanced diets and antioxidantdrugs are integral components of the comprehensive approach to the trauma patient suffering critical illness, and pertinent literatureis summarized.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.

Ventilation in the patient with unilateral lung disease

Severe ULD presents a challenge in ventilator management because of the marked asymmetry in the mechanics of the two lungs. The asymmetry may result from significant decreases or increases in the compliance of the involved lung. Traditional ventilator support may fail to produce adequate gas exchange in these situations and has the potential to cause further deterioration. Fortunately, conventional techniques can be safely and effectively applied in the majority of cases without having to resort to less familiar and potentially hazardous forms of support. In those circumstances when conventional ventilation is unsuccessful in restoring adequate gas exchange, lateral positioning and ILV have proved effective at improving and maintaining gas exchange. Controlled trials to guide clinical decision making are lacking. In patients who have processes associated with decreased compliance in the involved lung, lateral positioning may be a simple method of improving gas exchange but is associated with many practical limitations. ILV in these patients is frequently successful when differential PEEP is applied with the higher pressure to the involved lung. In patients in whom the pathology results in distribution of ventilation favoring the involved lung, particularly BPF, ILV can be used to supply adequate support while minimizing flow through the fistula and allowing it to close. The application of these techniques should be undertaken with an understanding of the pathophysiology of the underlying process; the reported experience with these techniques, including indications and successfully applied methods; and the potential problems encountered with their use. Fortunately, these modalities are infrequently required, but they provide a critical means of support when conventional techniques fail.

Independent lung ventilation

Situations in which independent lung ventilation may be of use include massive hemoptysis, pulmonary alveolar proteinosis, risk of interbronchial aspiration, unilateral lung injury, single lung transplant, and BPF. Any decision to attempt independent lung ventilation should take into consideration the many technical difficulties associated with the procedure. They include difficulties in the placement of DLTs and monitoring tube position, the risk of tube displacement, and the risk of airway trauma. The clinician also must consider the costs in terms of available manpower and resources. Maintaining a patient on independent lung ventilation requires highly skilled nursing care, specialized monitoring devices, and readily available FOB. Even with these limitations, independent lung ventilation may be of use in certain clinical situations when standard methods have failed.

Independent lung ventilation with a single ventilator using a variable resistance valve

Independent lung ventilation using two ventilators has been attempted in the treatment of acute respiratory failure due to unilateral lung disease. However, this method has been found to be cumbersome and difficult to use. We reasoned that a bifurcated endotracheal tube with a variable resistance valve may enable us to change the inspiratory airway pressures and, hence, the inspired tidal volume to one lung using a single ventilator. We tested this hypothesis in eight anesthetized sheep and created a bronchopleural fistula in one lung as a model of unilateral lung disease. A bifurcated endotracheal tube was placed to separate the ventilation to each lung and, through a "Y" connector, both right and left lungs were ventilated simultaneously with a single ventilator. A variable resistance valve was placed between the "Y" connector and the tube ventilating the experimental lung with bronchopleural fistula. With a ventilator-generated peak inspiratory pressure of 31 +/- 2 cm H2O, the airway pressure distal to the valve was randomly changed from 31 cm H2O to 23 +/- 2, 15 +/- 1, 8 +/- 1, and 0 cm H2O. This resulted in progressive diversion of tidal volume from the experimental lung to the control lung and an increase in exhaled tidal volume due to a decrease in air leak from the bronchopleural fistula. These data suggest that a variable resistance valve may be used for independent lung ventilation using a single ventilator.

Prolonged independent lung respiratory treatment after single lung transplantation in pulmonary emphysema

Single lung transplantation (SLT) is now successfully used in patients with severe emphysema. Mechanical imbalance between the native emphysematous and the healthy transplanted lung can be easily managed, unless severe graft failure occurs, leading to acute respiratory failure. Emergency retransplantation has been used in this setting, since the conventional approach to adult respiratory distress syndrome (ARDS) (mechanical ventilation and positive end-expiratory pressure [PEEP]) fails, due to the mechanical discrepancy between the two lungs. We describe two cases of severe graft failure following SLT in emphysema patients that were successfully treated with prolonged independent respiratory treatment. Mechanical ventilation and PEEP were applied to the failing transplanted lung while the native emphysematous lung was maintained on spontaneous breathing to avoid hyperexpansion and barotrauma. The independent lung respiratory treatment lasted 35 and 25 days, respectively: to our knowledge, these are among the longest-lasting independent respiratory treatments reported. The management was simplified by the early use of a double-lumen tracheostomy cannula as an alternative to orotracheal double lumen tube.

Differential lung ventilation with a double-lumen tracheostomy tube in unilateral refractory atelectasis

Two patients with refractory hypoxemia due to unilateral lung atelectasis were treated with differential lung ventilation (DLV) through a Robertshaw-type, double-lumen tracheostomy tube. DLV was applied using two non-synchronized ventilators and maintained for 6 and 3 days, respectively. Ventilator settings were chosen in accord to the clinical, laboratory and chest X-rays results. Particularly, tidal volume and PEEP were set to avoid excessively high alveolar pressure and to obtain the highest possible value of compliance. We investigated the mechanical properties of the two lungs separately by measuring airway pressure and compliance of each lung before the beginning of DLV and at 0, 5, 24, and 48 h after. Initially we observed in both patients very low values of compliance (7-9 cm H2O/l) and a significant level of PEEPi (12-8 cm H2O) of the diseased lung, whereas PEEPi in the healthy lung was negligible. The clinical improvement was assessed by sequential chest X-rays and by significant improvement of arterial blood gas and PaO2/FiO2 ratios and was associated with a progressive increase of compliance (24-22 cm H2O/l) and by a fall of PEEPi levels (5-4 cm H2O) of the diseased lung. We also observed an improvement of SvO2, O2AVI, PVRI and Qva/Qt values (Case 1). The tracheostomy tube used to apply DLV was very reliable, allowing easy nursing care and selective bronchial aspirations. We conclude that DLV is a very useful technique in unilateral lung pathology, and it can be a life saving procedure in selected patients, by supplying volume and PEEP more efficiently to the affected lung.

Lobar bronchial blockade in bronchopleural fistula

A 59-yr-old man with bullous lung disease developed a refractory bronchopleural fistula involving the right upper lobe. Despite independent lung and high-frequency jet ventilation, a large air leak persisted. Following the introduction of a bronchial blocker into the right upper lobe bronchus via the tracheal lumen of a left-sided endobronchial tube, oxygenation and ventilation improved, and the airleak was reduced by 90%. The presence of pneumonia led to an inexorably downhill course with death from overwhelming sepsis.