Intensive Care Unit, Ipswich Hospital NHS Trust, Heath Road, Ipswich IP4 5PD, UK 1Present address: Anaesthetic Department, Norfolk and Norwich Hospital, Brunswick Road, Norwich NR1 3SR, UK
Accepted for publication: May 27, 2000
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Abstract |
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Br J Anaesth 2000; 85: 78890
Keywords: ventilation, non-invasive; complications, trauma; complications, nosocomial pneumonia
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Introduction |
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Case report |
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A chest x-ray (Fig. 1) showed fractures of the secondninth ribs on the left, with disruption of the costovertebral joints, resulting in a large flail segment. There was severe contusion of most of the left lung and contusion of the right lower lobe. He had a disruption of his left shoulder joint, a large laceration over his left iliac crest, and a fractured left ankle. His Revised Trauma Score was 6.0, which represents an expected mortality of approximately 10%, and his Trauma Score Injury Severity Score (TRISS) expected mortality was 18%.1
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Computed tomography (CT) of the chest, cervical and thoracic spine, performed after stabilization confirmed the initial chest x-ray findings, as well as revealing bilateral small pneumothoraces and fractures of many of the spinous processes of the thoracic vertebrae. The neural arches were, however, intact and there was no evidence of spinal cord injury. The cervical spine appeared normal.
The patients lungs were ventilated using volume controlled ventilation, with a positive end-expiratory pressure (PEEP) of 6 cm H2O, and an FIO2 of 0.35 (Servo 900C ventilator, Siemens-Elema, Sweden). This resulted in an arterial oxygen partial pressure (PaO2) of 13.7 kPa. He was thought not to require an open lung strategy as his peak airway pressure was acceptable (<25 cm H2O), and oxygenation was not problematic. His initial cardiovascular instability was such that high levels of PEEP were thought inadvisable.
After a 48-h period of stabilization, and once his coagulopathy (a result of the massive transfusion) had been treated by infusion of fresh frozen plasma and cryoprecipitate, a thoracic epidural was inserted at the T7/8 level, and infusion of bupivacaine commenced. The epidural provided good analgesia for the thoracic injuries, but the shoulder fracture continued to produce a lot of pain. A patient-controlled analgesia infusion of morphine was therefore also commenced. These infusions resulted in good analgesia, ventilatory support was weaned off, and his trachea was extubated on the fourth day after admission.
On day 5, increasing oxygen requirement was treated with periods of intermittent positive pressure breathing (IPPB) via a Bird ventilator and continuous positive airway pressure (CPAP) by facemask. IPPB is a form of treatment, usually administered by the physiotherapists, which is designed to reinflate collapsed pulmonary segments and so reduce shunting of deoxygenated blood. The patient uses a mouthpiece; the lungs are ventilated with a constant pressure. Despite this, by day 7 his FIO2 had risen to 0.6, giving a PaO2 of only 9 kPa. Facial CPAP at a level of 7.5 cm H2O was continued and negative fluid balances were obtained by fluid restriction and forced diuresis by loop diuretics. Fluid balance was monitored in the usual way by detailed input/output charts and urethral catheterization. These treatments resulted in reduction of his FIO2 to 0.45.
On day 9, after internal fixation of his ankle, the patients lungs were ventilated overnight. Following tracheal extubation the next morning, he was given CPAP at a level of 7.5 cm H2O by facemask. At this stage he still had a large flail segment, and radiological and clinical evidence of continuing contusion in his left lung. The right basal contusion had now resolved.
Over the next 72 h, the patient developed increasing respiratory distress, with an increasing respiratory rate (up to 50 b.p.m.), shallow breathing and an uneven respiratory pattern, and the FIO2 had increased to 0.6, in order to maintain a PaO2 of 10 kPa. On day 12, NIPPV was commenced via a nasal mask (NIPPY2 ventilator, Aeromed, UK), with an immediate reduction in his oxygen requirements. He remained on continuous nasal NIPPV for a further 9 days, with a reducing level of pressure support and CPAP; the NIPPV was tolerated extremely well throughout. His invasive lines were all removed on day 18.
By day 20, he was receiving only intermittent NIPPV, and otherwise had an oxygen saturation (SaO2) of 98% on 3 litres min1 of oxygen via nasal cannulae. On day 22, he was given NIPPV overnight only, and the NIPPV was discontinued on day 24. Nocturnal CPAP by facemask continued for a further night, and he was discharged to the ward on day 26.
Apart from a 5-day course of flucloxacillin to treat a Staphylococcus aureus infection in a laceration, the patient required no antibiotics during his stay on the intensive care unit (ICU). At no stage was there any evidence of systemic or pulmonary infection.
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Discussion |
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NIPPV has been shown to be as effective as conventional ventilation in a variety of settings, including exacerbations of chronic obstructive pulmonary disease12 and acute respiratory failure.13 The causes of the acute respiratory failure in the latter paper ranged from infection and pulmonary oedema to acute respiratory distress syndrome. To date, there have been no reports of the use of NIPPV in severe chest trauma.14
Nava et al.12 allocated random patients with exacerbations of chronic obstructive pulmonary disease to either NIPPV or conventional ventilation, after an initial period of 48 h conventional ventilation. Seven out of 25 patients in the conventionally ventilated group developed ventilator- associated pneumonia, compared to none of the NIPPV group (P=0.009). Antonelli et al.13 allocated random patients to either NIPPV or conventional ventilation from the outset. Again, the patients ventilated non-invasively had a significantly lower incidence of ventilator-associated pneumonia and sinusitis. While this study had some minor methodological flaws, it demonstrates a clear difference in infective complications between the two groups, and adds further evidence to the hypothesis discussed above, that avoidance of tracheal intubation reduces the incidence of ventilator-associated pneumonia, and thus decreases length of ICU stay and other variables.6
Thoracic injury consists of a spectrum of disease, ranging from rib fractures with mild pulmonary contusion to disruption of the thoracic cage and acute respiratory distress syndrome. Although many of the less severely injured patients are now managed without ventilatory support, with a thoracic epidural and aggressive chest physiotherapy,14 there will always be a number for whom this is not sufficient. These patients, usually with significant hypoxaemia, often require an extended period of invasive ventilation,15 and the risk of ventilator-associated pneumonia is thus high. We believe that in this group, avoidance of tracheal intubation and hence avoidance of ventilator-associated pneumonia may be a major step in reducing ICU stay, morbidity and mortality. NIPPV is safe, effective, and, we believe, may be the mode of choice for managing patients with thoracic trauma who have no contraindications to its use. We have since used NIPPV in a further two patients with bilateral flail chest and lesser degrees of pulmonary contusion, and had very similar results with regard to effectiveness of the ventilatory support, and avoidance of ventilator-associated pneumonia.
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Footnotes |
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References |
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