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• W1555389723 abstract "To the Editor: The presence of intrinsic positive end-expiratory pressure (PEEP), or auto-PEEP, is now a widely recognized source of problems in the management of patients in the intensive care unit (ICU). It becomes greater when patients with COPD need mechanical ventilation despite the use of long expiratory time, intensive bronchodilator treatment, and the use of partial ventilatory support as early as possible. We report the case of a COPD patient who showed auto-PEEP in spite of use of the aforementioned strategies and in whom an important role in the increased expiratory resistance could be attributed to dynamic compression of the trachea. A 70-year-old man was admitted with a history of acute febrile decompensation of COPD. His past medical history included gastrectomy for peptic ulcer 20 years previously and COPD due to a long-term smoking habit; the COPD had been treated regularly with continuous home oxygen, corticosteroids, and bronchodilators. Pulmonary function tests showed the following values: FVC, 2,130 ml (54 percent of predicted); FEV1, 740 ml (26 percent); FEF25-75%, 300 ml (14 percent) of predicted. A bronchodilator test was positive. In the previous three months, he had suffered two attacks of severe bronchospasm necessitating hospitalization. On the day of admission, he suddenly became dyspneic with cyanosis and diaphoresis. Arterial blood gas analysis showed mild hypoxemia and severe hypercapnia with respiratory acidosis (PaO2, 65 mm Hg; PaCO2, 65 mm Hg; and pH, 7.14 with 24 percent inspired O2). After 2 h, his clinical condition and blood gas values had deteriorated (PaO2, 63 mm Hg; PaCO2, 94 mm Hg; and pH, 7.01 with 30 percent inspired O2). The patient was admitted to the ICU, and noninvasive mechanical ventilation with pressure support via a face mask was instituted with initially good results. After several hours the bronchospasm became aggravated, and endotracheal intubation was required. After vigorous intravenous bronchodilator treatment, wheezes persisted, and tests of lung mechanics revealed an inspiratory airway resistance of 27 cm H2O/L/s, static compliance of 70 ml/cm H2O, and auto-PEEP of 8 cm H2O. Fiberoptic bronchoscopy showed indentation of the posterior wall of the trachea into the lumen during expiration with a critical reduction in airway diameter. External PEEP was added in a steplike manner under direct vision via the bronchoscope. The inward motion of the posterior wall of the trachea progressively decreased until the maximum reduction was reached at 8 cm H2O (Fig 1). Neither peak and plateau airway pressures nor auto-PEEP increased. The wheezes disappeared, and the capnogram profile showed a reduction in the slope of CO2 elimination from 5 to 2 mm Hg/s.1Blanch L, Fernández R, Artigas A. The effect of autoPEEP on the PaCO2-PetCO2 gradient and expired CO2 slope in critically ill patients during total ventilatory support. J Crit Care (in press)Google Scholar The patient died three days later of septic shock caused by Pseudomonas pneumonia. Auto-PEEP is attributed to high minute ventilation, short expiratory time, small diameter of endotracheal tubes, and, more often than not, elevated airway resistance. It is normally a function of small airway tone, mucous plugging, and dynamic collapse.2Marini JJ Should PEEP be used in airflow obstruction?.Am Rev Respir Dis. 1989; 140: 1-3Crossref PubMed Scopus (121) Google Scholar While bronchomalacia is a common disorder in COPD patients, the weakness of the posterior wall of the trachea to such an elevated degree is exceptional. Moreover, to our knowledge it has not been described as a source of this amount of auto-PEEP. The reponse to external PEEP suggests an internal pneumatic stabilization component.3Smith TC Marini JJ Impact of PEEP on lung mechanics and work of breathing in severe airflow obstruction.J Appl Physiol. 1988; 65: 1488-1499Crossref PubMed Scopus (348) Google Scholar" @default.
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• W1555389723 date "1992-08-01" @default.
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• W1555389723 title "Auto-PEEP Is Favored by Weakness of the Posterior Wall of the Trachea" @default.
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• W1555389723 doi "https://doi.org/10.1378/chest.102.2.655" @default.
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