Ventilation by the Open Lung Concept in spite of traumatic lung herniation

D. Schreiter*,1, A. Reske1, C. Glien1, L. Scheibner1 and C. Josten2

1 Surgical Intensive Care Unit, and 2 Division of Traumatology, Department of Surgery, University of Leipzig, Liebigstrasse 20a, D-04103 Leipzig, Germany

Corresponding author. E-mail: dschr@medizin.uni-leipzig.de

Accepted for publication: November 4, 2002


    Abstract
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Traumatic herniation of the lung is uncommon. We report a patient suffering from multiple injuries including severe pulmonary contusion and traumatic parasternal lung herniation, who developed acute respiratory distress syndrome. In spite of the lung herniation, we used mechanical ventilation according to the Open Lung Concept. Oxygenation improved rapidly, and early operative stabilization was possible.

Br J Anaesth 2003; 90: 385–7

Keywords: complications, acute respiratory distress syndrome; lung, damage; ventilation, mechanical


    Introduction
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
Herniation of the lung is rare. Most reported cases are caused by thoracic trauma.1 2 Sternocostal lung herniation after road traffic accidents are part of the ‘seatbelt syndrome’.3


    Case report
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
A 74-yr-old woman, travelling as a restrained passenger, was involved in a high-speed motor vehicle accident. At primary examination she had a Glasgow Coma Score of 15, multiple left rib fractures and a proximal right femur fracture. After admission to hospital, she had moderate to severe respiratory distress and complained of shortness of breath. Tracheal intubation was carried out and mechanical ventilation started. A chest drain was placed on the left side, and the patient was transferred to a trauma centre.

The patient was morbidly obese (BMI 52 kg m–2). She had a sinus tachycardia of 133 beats min–1 and an arterial pressure of 110/70 mm Hg. Mechanical ventilation was volume-cycled with an inspiratory/expiratory ratio (I/E) of 1:1, PEEP of 10 cm H2O, ventilatory frequency of 16 bpm, and a tidal volume (VT) of 800 ml. Arterial blood gases were PaO2 7.2 kPa and PaCO2 8.1 kPa with FIO2 1.0. Thorough examination and CT-scans showed a flail chest with multiple left-sided lateral and parasternal rib fractures, severe pulmonary contusion, left haemothorax, and a large parasternal herniation of the left lung (Fig. 1). Fractures of the cervical spine (C2) and the proximal right femur were present. We calculated an Injury Severity Score of 29, and an Abbreviated Injury Score (Thorax) of 4.4 5



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Fig 1 The initial CT-scan showed a left haemothorax and the anterior parasternal herniation of the left lung with s.c. emphysema.

 
Because of severe hypoxaemia, we applied the Open Lung Concept (OLC).6 7 Sedation was increased and further monitoring started. We used a continuous blood gas monitor (TrendcareTM, Agilent Technologies, Böblingen, Germany) to follow PaO2, PaCO2, and pH. Ventilation was changed to a pressure-cycled mode, with I/E 2:1, PEEP 10 cm H2O, inspiratory pressure (PIP) of 30 cm H2O and ventilatory frequency 30 bpm. Before the recruitment procedure, ventilatory frequency was increased to 80 bpm, and then PIP was increased to 65 cm H2O for five breaths (Table 1). Three consecutive recruitment procedures were applied, until the required PEEP was found to keep the lung open (Fig. 2). During application of the opening pressures, the defective chest area was stabilized by manual compression. To generate additional intrinsic PEEP, we maintained the high ventilatory frequency and pressure-cycled inverse-ratio-ventilation. After the recruitment procedure, PaO2 increased to 77 kPa and after 5 min to 90 kPa. Therefore, a rapid decrease of FIO2 was possible. We maintained ventilation according to the OLC for the following 90 h (Table 1). We also used continuous rotational therapy (Rotorest®-bed, KCI, Wiesbaden, Germany). After restoration of the oxygenation, the defective chest wall was stabilized with wire cerclage on day 7. Afterwards the femoral fracture was internally fixed using a proximal femur nail. The fracture of the cervical spine was treated conservatively, because no instability was found. Because of prolonged intubation, a percutaneous tracheostomy was performed on day 9. On day 14, oxygenation worsened because of pneumonia, which required another application of the OLC for 40 h. We started to wean the respiratory support on day 20, which was complicated by the massive obesity. However, the patient breathed without support on day 26. Eight days later, the tracheostomy was removed, and she was discharged after 38 days. Complete healing of the thoracic injuries was seen on repeat CT (Fig. 3).


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Table 1 Respiratory values before and after the recruitment manoeuvre (RM). The values were obtained before RM, during RM and at specific times after RM. During recruitment, no explicit tidal volume was measured (*)
 


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Fig 2 Values from the blood gas monitor showing PaO2 and PaCO2. The vertical line indicates the start of the OLC. Temporary deterioration of oxygenation (arrows) was treated by further recruitment procedures.

 


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Fig 3 A follow-up CT-scan shows repair of the costo-sternal junction and the left lung returned to the pleural space. The lungs are normal.

 

    Discussion
 Top
 Abstract
 Introduction
 Case report
 Discussion
 References
 
We describe a patient with multiple injuries including severe pulmonary contusion and traumatic lung herniation. Although lung herniation is considered to be a concomitant injury that is not life-threatening in most cases,13 its combination with severe lung contusion, multiple injuries, old age, and excessive weight were life-threatening in this patient. Pulmonary contusion caused acute respiratory distress syndrome (ARDS).8 In ARDS dependent dorsal atelectasis causes overinflation of the upper parts of the lung especially during ventilation with high pressures.9 Overinflation is aggravated if instability of the chest wall occurs. The OLC can be effective in patients with severe pulmonary contusion.7 10 Our experience supported these reports. The pressures we used during the recruitment manoeuvre are based on our experimental and clinical experience.7 Because of the high airway pressures used in the recruitment manoeuvre and the poor support from the chest wall, we were not sure if lung herniation was a contraindication. Nevertheless, we used the OLC, and stabilized the flail chest area by manual compression to prevent further herniation and hyperinflation of the herniated lung. No signs of hyperinflation of lung tissue such as traumatic bullae or incarceration were found at surgery. The rapid resolution of hypoxaemia enabled early surgical repair.


    References
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
1 Hiscoe B, Digman J. Types and incidence of lung hernias. J Thorac Cardiovasc Surg 1955; 30: 335–42

2 Scullion DA, Negus R, Al-Kutoubi A. Case report: extrathoracic herniation of the lung with a review of the literature. Br J Radiol 1994; 67: 94–6[Abstract]

3 May AK, Chan B, Daniel TM, and Young JS. Anterior lung herniation: another aspect of the seatbelt syndrome. J Trauma 1995; 38: 587–9[ISI][Medline]

4 Baker SP, O’Neill B, Haddon W, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974; 14: 187–96[ISI][Medline]

5 Civil ID, and Schwab CW. The Abbreviated Injury Scale, 1985 Revision: a condensed chart for clinical use. J Trauma 1988; 28: 87–90[ISI][Medline]

6 Lachmann B. Open up the lung and keep the lung open. Intensive Care Med 1992; 18: 319–21[ISI][Medline]

7 Schreiter D, Reske A, Scheibner L, et al. The Open Lung Concept. A clinical trial in severe chest trauma. Der Chirurg 2002; 73: 353–59[CrossRef]

8 Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS. Am J Respir Crit Care Med 1994; 149: 818–24[Abstract]

9 Gattinoni L, Caironi P, Pelosi P, and Goodman LR. What has computed tomography taught us about the acute respiratory distress syndrome? Am J Respir Crit Care Med 2001; 164: 1701–11[Free Full Text]

10 Knothe C, Huber T, Hiltl P, et al. Ventilation according to the ‘open lung’ concept of multiple trauma patients. Anasthesiol Intensivmed Notfallmed Schmerzther 2000; 35: 306–15[CrossRef][ISI][Medline]





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