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A5274 - Independent Lung Ventilation in Asymmetric Acute Respiratory Distress Syndrome
Author Block: W. Rodriguez1, L. Gonzalez1, A. Candelario2, J. Torres-Palacios3, A. Torres-Palacios1, Y. Otero1, O. J. Cantres Fonseca4; 1Pulm/CCM/Sleep, VA Caribbean Healthcare System, San Juan, PR, United States, 2VA Caribbean Healthcare System, Guaynabo, PR, United States, 3VA Caribbean Healthcare System, San Juan, PR, United States, 4Veterans Affair, San Juan, PR, United States.
Independent lung ventilation (ILV) has a well-defined role in anesthesia during thoracic surgeries, the role in the critical care setting is not well-established. ARDS diagnosis is defined by the Berlin criteria. Even though ARDS is a diffuse injury asymmetric damage is frequent and more often when secondary to pulmonary causes. No high-quality data is available about the benefit of ILV in asymmetric ARDS.
A 69-year-old man with B-Cell Acute Lymphoblastic Leukemia s/p Allogeneic Hematopoietic Stem Cell Transplantation on May 2016, long-term immunosuppressive and prophylactic therapy, hypertension, Diabetes Mellitus type 2 and Coronary Artery Disease was brought to ED after development of progressive shortness of breath, non-productive cough, watery diarrhea, and fever (104F) with chills. Initial evaluation remarkable for decreased breath sounds in left hemithorax. He rapidly deteriorated at ED w hypotension and tachycardia unresponsive to of 5 liters IV 0.9NSS, been started on norepinephrine, dopamine and Vancomycin, metronidazole, and Imipenem-Cilastin. Given respiratory distress she was endotracheally intubated, placed on mechanical ventilation and admitted to ICU. CXR and ABGs were compatible with severe ARDS. MV parameters were adjusted due to refractory hypoxemia and ARDS in accordance to lung protective ventilation. Patient’s oxygenation worsened overnight requiring manual ventilation which resulted in improved saturation. Based on the difficulty to ventilate both lungs with the same parameters we decided to provide dual-lumen bi-bronchial intubation with independent synchronized lung ventilation. The pO2/FiO2 ratio improved to 120mmHg. Patient developed refractory spontaneous nasal bleeding secondary to severe thrombocytopenia and DIC which worsened the patient’s already unstable hemodynamic status and in conjunction with septic shock caused his demise three days after his admission.
In conventional ventilation with single-lumen endotracheal tube, most of the tidal volume is diverted to the normal, more compliant lung, which will be disproportionately distended when compared with the diseased lung. The application of bilateral PEEP with conventional ventilation may also be inadequate for alveolar recruitment in the diseased lung and, simultaneously, excessive in the normal lung, causing hyperinflation. In the case that we are presenting physiological separation with synchronous ventilation that was successfully utilized to improve oxygenation and alveolar ventilation with improved CO2 clearance and decreased overall FiO2 requirements. This case exemplifies the utility of ILV in the setting of asymmetric ARDS and could be applied to other unilateral or asymmetric pulmonary parenchymal diseases.