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• W2023447524 abstract "In a 64-year-old ventilated patient with severe chronic obstructive pulmonary disease and extensive unilateral pneumonia, intrinsic PEEP became recognized when the chest roentgenogram showed unilateral lung hyperinflation and herniation of a large bulla to the contralateral hemithorax. The use of an on-line suction catheter may have contributed to the development of intrinsic PEEP. Removal of the catheter resulted in roentgenographic and clinical improvement. In a 64-year-old ventilated patient with severe chronic obstructive pulmonary disease and extensive unilateral pneumonia, intrinsic PEEP became recognized when the chest roentgenogram showed unilateral lung hyperinflation and herniation of a large bulla to the contralateral hemithorax. The use of an on-line suction catheter may have contributed to the development of intrinsic PEEP. Removal of the catheter resulted in roentgenographic and clinical improvement. The occurrence of occult or “intrinsic” PEEP has been well documented.1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar, 2Rossi A Gottfried SB Zocchi L Higgs BD Lennox S Calverley PMA et al.Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation.Am Rev Respir Dis. 1985; 131: 672-677PubMed Google Scholar, 3Black JW Grover BS A hazard of pressure support ventilation.Chest. 1988; 93: 333-335Crossref PubMed Scopus (29) Google Scholar, 4Derenne JP Fleury B Pariente R Acute respiratory failure of chronic obstructive pulmonary disease.Am Rev Respir Dis. 1988; 138: 1006-1033Crossref PubMed Scopus (107) Google Scholar Patients with a prolonged expiratory time constant secondary to either increased airway resistance or a decreased elastic recoil are at high risk. Manifestations of intrinsic PEEP have ranged from overt hemodynamic compromise to unexplained hypoxemia, hypercarbia, tachycardia, and oliguria.1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar,3Black JW Grover BS A hazard of pressure support ventilation.Chest. 1988; 93: 333-335Crossref PubMed Scopus (29) Google ScholarWe describe an unusual roentgenographic and clinical manifestation of intrinsic PEEP In this patient, intrinsic PEEP became recognized when the chest roentgenogram showed unilateral lung hyperinflation and herniation of a large bulla to the contralateral hemithorax. This resulted in the hemodynamic responses of tachycardia and hypotension.Case ReportA 64-year-old man with chronic obstructive pulmonary disease became febrile after remaining stable for five years on mechanical ventilation. Chest roentgenogram showed a right upper lobe infiltrate, a left upper lobe bulla, and generalized hyperinflation. Culture of endotracheal secretions revealed Pseudomonas aeruginosa. The patient was ventilated with an FIo2 of 28 percent, tidal volume of 800 ml, in assist/control mode. Delivered minute ventilation was 8 to 10 L/min and peak inspiratory pressure was 35 cm H2O. Despite appropriate antibiotic therapy, the infiltrate cavitated and progressed roentgenographically to involve the right lower lobe. Intrinsic PEEP, measured after transient occlusion of the expiratory ventilator tubing,1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar was 10 cm H2O. An on-line suction catheter (TRACHCARE closed tracheal suction system, Ballard Med Products, Midvale, Utah) was added to the ventilator apparatus to facilitate suctioning. Routine chest roentgenograms on subsequent days revealed left lung hyperinflation with resultant herniation of the upper lobe bulla across the midline (Fig 1). Repeated measurements for intrinsic PEEP during this time were 20 cm H2O. In addition, his systolic blood pressure, which had been measured at 120 mm Hg, was reduced to 90 to 100 mm Hg. In response, his heart rate rose to approximately 120 beats per minute. Bronchoscopy showed no proximal endobronchial obstruction, but the chest roentgenogram immediately after the procedure showed partial resolution of the apparent lung herniation, which then recurred following reinstitution of mechanical ventilation. The on-line suction apparatus was removed and the patient was intermittently manually suctioned. Although little improvement in the patient's pneumonia was noted, subsequent chest roentgenograms demonstrated improvement in the left lung hyperinflation and a decrease in the size of the left upper lobe bullous lesion (Fig 2). Furthermore, the patient's blood pressure subsequently increased and heart rate decreased to their previous levels. Intrinsic PEEP was persistently measured at this point at approximately 10 cm H2O.Figure 2On-line suction catheter removal resulted in reduced intrinsic PEEP and reversal of left lung herniation and mediastinal shift.View Large Image Figure ViewerDownload (PPT)DiscussionRoutine chest roentgenograms in patients in the intensive care unit are inadequate for demonstrating the presence of PEEP, whether applied or intrinsic, as increased lung distention may be subtle and easily overlooked. However, in patients with air trapping due to severe obstructive airway disease who develop unilateral lung disease, the uninvolved lung may be relatively more compliant and thus more susceptible to the effects of intrinsic PEEP. Such an occurrence has, in fact, been reported previously with the use of applied PEEP in a patient with unilateral lung consolidation.5Carlon GC Kahn R Howland WS Baron R Ramaker J Acute life-threatening ventilation-perfusion inequality: an indication for independent lung ventilation.Crit Care Med. 1978; 6: 380-383Crossref PubMed Scopus (41) Google ScholarOur patient demonstrates that intrinsic PEEP may also be unequally distributed in patients with asymmetric lung disease.After worsening of intrinsic PEEP was confirmed, our patient underwent bronchoscopy first to rule out proximal endobronchial obstruction and was then removed from the on-line suction apparatus. An immediate decrease in the intrinsic PEEP was demonstrated when the patient was intermittently removed from the ventilator for manual suctioning or for bronchoscopy. In response to this decrease in intrinsic PEEP, an improvement in the chest roentgenogram was noted.This case therefore demonstrates that intrinsic PEEP may manifest roentgenographically in patients with unequal or asymmetric lung compliance. Chest roentgenograms should be reviewed carefully for evidence of progressive hyperinflation in patients at risk for intrinsic PEEP to avert potential hemodynamic complications or barotrauma. In addition, we postulate that the unilateral hyperinflation was worsened by the application of an on-line suction apparatus to the ventilator circuit. By obviating the need for removal of the patient from the ventilator for suctioning, it eliminated intermittent release of high intrathoracic volume caused by air trapping. Periodic interruption of mechanical ventilation may thus deflate the lungs and ameliorate the effects of intrinsic PEEP. On-line suction catheters should therefore be used with caution in such patients. The occurrence of occult or “intrinsic” PEEP has been well documented.1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar, 2Rossi A Gottfried SB Zocchi L Higgs BD Lennox S Calverley PMA et al.Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation.Am Rev Respir Dis. 1985; 131: 672-677PubMed Google Scholar, 3Black JW Grover BS A hazard of pressure support ventilation.Chest. 1988; 93: 333-335Crossref PubMed Scopus (29) Google Scholar, 4Derenne JP Fleury B Pariente R Acute respiratory failure of chronic obstructive pulmonary disease.Am Rev Respir Dis. 1988; 138: 1006-1033Crossref PubMed Scopus (107) Google Scholar Patients with a prolonged expiratory time constant secondary to either increased airway resistance or a decreased elastic recoil are at high risk. Manifestations of intrinsic PEEP have ranged from overt hemodynamic compromise to unexplained hypoxemia, hypercarbia, tachycardia, and oliguria.1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar,3Black JW Grover BS A hazard of pressure support ventilation.Chest. 1988; 93: 333-335Crossref PubMed Scopus (29) Google Scholar We describe an unusual roentgenographic and clinical manifestation of intrinsic PEEP In this patient, intrinsic PEEP became recognized when the chest roentgenogram showed unilateral lung hyperinflation and herniation of a large bulla to the contralateral hemithorax. This resulted in the hemodynamic responses of tachycardia and hypotension. Case ReportA 64-year-old man with chronic obstructive pulmonary disease became febrile after remaining stable for five years on mechanical ventilation. Chest roentgenogram showed a right upper lobe infiltrate, a left upper lobe bulla, and generalized hyperinflation. Culture of endotracheal secretions revealed Pseudomonas aeruginosa. The patient was ventilated with an FIo2 of 28 percent, tidal volume of 800 ml, in assist/control mode. Delivered minute ventilation was 8 to 10 L/min and peak inspiratory pressure was 35 cm H2O. Despite appropriate antibiotic therapy, the infiltrate cavitated and progressed roentgenographically to involve the right lower lobe. Intrinsic PEEP, measured after transient occlusion of the expiratory ventilator tubing,1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar was 10 cm H2O. An on-line suction catheter (TRACHCARE closed tracheal suction system, Ballard Med Products, Midvale, Utah) was added to the ventilator apparatus to facilitate suctioning. Routine chest roentgenograms on subsequent days revealed left lung hyperinflation with resultant herniation of the upper lobe bulla across the midline (Fig 1). Repeated measurements for intrinsic PEEP during this time were 20 cm H2O. In addition, his systolic blood pressure, which had been measured at 120 mm Hg, was reduced to 90 to 100 mm Hg. In response, his heart rate rose to approximately 120 beats per minute. Bronchoscopy showed no proximal endobronchial obstruction, but the chest roentgenogram immediately after the procedure showed partial resolution of the apparent lung herniation, which then recurred following reinstitution of mechanical ventilation. The on-line suction apparatus was removed and the patient was intermittently manually suctioned. Although little improvement in the patient's pneumonia was noted, subsequent chest roentgenograms demonstrated improvement in the left lung hyperinflation and a decrease in the size of the left upper lobe bullous lesion (Fig 2). Furthermore, the patient's blood pressure subsequently increased and heart rate decreased to their previous levels. Intrinsic PEEP was persistently measured at this point at approximately 10 cm H2O. A 64-year-old man with chronic obstructive pulmonary disease became febrile after remaining stable for five years on mechanical ventilation. Chest roentgenogram showed a right upper lobe infiltrate, a left upper lobe bulla, and generalized hyperinflation. Culture of endotracheal secretions revealed Pseudomonas aeruginosa. The patient was ventilated with an FIo2 of 28 percent, tidal volume of 800 ml, in assist/control mode. Delivered minute ventilation was 8 to 10 L/min and peak inspiratory pressure was 35 cm H2O. Despite appropriate antibiotic therapy, the infiltrate cavitated and progressed roentgenographically to involve the right lower lobe. Intrinsic PEEP, measured after transient occlusion of the expiratory ventilator tubing,1Pepe PE Marini JJ Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction.Am Rev Respir Dis. 1982; 126: 166-170PubMed Google Scholar was 10 cm H2O. An on-line suction catheter (TRACHCARE closed tracheal suction system, Ballard Med Products, Midvale, Utah) was added to the ventilator apparatus to facilitate suctioning. Routine chest roentgenograms on subsequent days revealed left lung hyperinflation with resultant herniation of the upper lobe bulla across the midline (Fig 1). Repeated measurements for intrinsic PEEP during this time were 20 cm H2O. In addition, his systolic blood pressure, which had been measured at 120 mm Hg, was reduced to 90 to 100 mm Hg. In response, his heart rate rose to approximately 120 beats per minute. Bronchoscopy showed no proximal endobronchial obstruction, but the chest roentgenogram immediately after the procedure showed partial resolution of the apparent lung herniation, which then recurred following reinstitution of mechanical ventilation. The on-line suction apparatus was removed and the patient was intermittently manually suctioned. Although little improvement in the patient's pneumonia was noted, subsequent chest roentgenograms demonstrated improvement in the left lung hyperinflation and a decrease in the size of the left upper lobe bullous lesion (Fig 2). Furthermore, the patient's blood pressure subsequently increased and heart rate decreased to their previous levels. Intrinsic PEEP was persistently measured at this point at approximately 10 cm H2O. DiscussionRoutine chest roentgenograms in patients in the intensive care unit are inadequate for demonstrating the presence of PEEP, whether applied or intrinsic, as increased lung distention may be subtle and easily overlooked. However, in patients with air trapping due to severe obstructive airway disease who develop unilateral lung disease, the uninvolved lung may be relatively more compliant and thus more susceptible to the effects of intrinsic PEEP. Such an occurrence has, in fact, been reported previously with the use of applied PEEP in a patient with unilateral lung consolidation.5Carlon GC Kahn R Howland WS Baron R Ramaker J Acute life-threatening ventilation-perfusion inequality: an indication for independent lung ventilation.Crit Care Med. 1978; 6: 380-383Crossref PubMed Scopus (41) Google ScholarOur patient demonstrates that intrinsic PEEP may also be unequally distributed in patients with asymmetric lung disease.After worsening of intrinsic PEEP was confirmed, our patient underwent bronchoscopy first to rule out proximal endobronchial obstruction and was then removed from the on-line suction apparatus. An immediate decrease in the intrinsic PEEP was demonstrated when the patient was intermittently removed from the ventilator for manual suctioning or for bronchoscopy. In response to this decrease in intrinsic PEEP, an improvement in the chest roentgenogram was noted.This case therefore demonstrates that intrinsic PEEP may manifest roentgenographically in patients with unequal or asymmetric lung compliance. Chest roentgenograms should be reviewed carefully for evidence of progressive hyperinflation in patients at risk for intrinsic PEEP to avert potential hemodynamic complications or barotrauma. In addition, we postulate that the unilateral hyperinflation was worsened by the application of an on-line suction apparatus to the ventilator circuit. By obviating the need for removal of the patient from the ventilator for suctioning, it eliminated intermittent release of high intrathoracic volume caused by air trapping. Periodic interruption of mechanical ventilation may thus deflate the lungs and ameliorate the effects of intrinsic PEEP. On-line suction catheters should therefore be used with caution in such patients. Routine chest roentgenograms in patients in the intensive care unit are inadequate for demonstrating the presence of PEEP, whether applied or intrinsic, as increased lung distention may be subtle and easily overlooked. However, in patients with air trapping due to severe obstructive airway disease who develop unilateral lung disease, the uninvolved lung may be relatively more compliant and thus more susceptible to the effects of intrinsic PEEP. Such an occurrence has, in fact, been reported previously with the use of applied PEEP in a patient with unilateral lung consolidation.5Carlon GC Kahn R Howland WS Baron R Ramaker J Acute life-threatening ventilation-perfusion inequality: an indication for independent lung ventilation.Crit Care Med. 1978; 6: 380-383Crossref PubMed Scopus (41) Google ScholarOur patient demonstrates that intrinsic PEEP may also be unequally distributed in patients with asymmetric lung disease. After worsening of intrinsic PEEP was confirmed, our patient underwent bronchoscopy first to rule out proximal endobronchial obstruction and was then removed from the on-line suction apparatus. An immediate decrease in the intrinsic PEEP was demonstrated when the patient was intermittently removed from the ventilator for manual suctioning or for bronchoscopy. In response to this decrease in intrinsic PEEP, an improvement in the chest roentgenogram was noted. This case therefore demonstrates that intrinsic PEEP may manifest roentgenographically in patients with unequal or asymmetric lung compliance. Chest roentgenograms should be reviewed carefully for evidence of progressive hyperinflation in patients at risk for intrinsic PEEP to avert potential hemodynamic complications or barotrauma. In addition, we postulate that the unilateral hyperinflation was worsened by the application of an on-line suction apparatus to the ventilator circuit. By obviating the need for removal of the patient from the ventilator for suctioning, it eliminated intermittent release of high intrathoracic volume caused by air trapping. Periodic interruption of mechanical ventilation may thus deflate the lungs and ameliorate the effects of intrinsic PEEP. On-line suction catheters should therefore be used with caution in such patients." @default.
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• W2023447524 title "Unilateral Lung Hyperinflation and Herniation as a Manifestation of Intrinsic PEEP" @default.
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