The effect of pressure support ventilation on auto-PEEP in a patient with asthma.

H Tokioka, S Saito, S Saeki, M Kinjo and F Kosaka Chest 1992;101;285-286 DOI 10.1378/chest.101.1.285 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/101/1/285

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1992by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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live

pneumonia secondary to other organisms. This differ- are breathing spontaneously during continuous positive has significant therapeutic implications since, airway pressure ventilation or pressure support ventilation (PSV). The effect of PSV on auto-PEEP is also unclear. We unlike a simple postobstructive infection, pneumonia seereport the effect of PSV on auto-PEEP in a patient with ondary to Actinomyces requires prolonged antibiotic therapy. We elected to treat our patient for actinomycotic asthma. pneumonia and, after removing the obstructing foreign body CASE REPORT via rigid bronchoscopy, initiated a two-week course of intravenous penicillin therapy followed by six months of oral A 77-year-old woman with history of asthma a was admitted to our hospital for a lung tumor detected on chest roentgenogram. therapy. She had no history ofchronic bronchitis or emphysema. Admission Primary endobronchial actinomycosis must be considered diagnosis was lung abscess. Preoperatively, the airways appeared to in the differential diagnosis of an endobronchial mass, as be normal by bronchoscopy. Partial resection of the right upper well as a complication of foreign body aspiration. When lobe ofthelungwas performed. After surgery she was not extubated sulfur granules are noted on routine histologic or cytologic because wheezing was noted. There was no postoperative hemorexamination ofmaterial obtained at bronchoscopy, additional rhage in the airway. She was transferred to the intensive care unit stains will confirm the diagnosis of actinomycotic infection (ICU) and ventilated with PSV (7200a, Puritan-Bennett, Los Anby revealing non-acid-fast filamentous microorganisms staingeles, CA) through a 7.0-Fr size endotracheal tube. PSV level was ing positively with Cram stain and Gomori methenamine 10 cm H,O. Twenty minutes after transfer to the ICU, she showed silver. marked respiratory effort with use of accessory muscles. An attack of asthma developed and she complained of dyspnea. Ventilation REFERENCES was continued at PSV 10 cm H5O without PEEP. Aminophylline, 1 Lerner P! Actinomyces and Arachnia species. In: Mandle CL, 250 mg, was given intravenously, and salbutamol was also given by Douglas RG, BennettJE, eds. Principles and practiceof infectious inhalation. One hour after treatment the dyspnea disappeared,
entiation
diseases.

3rd

ed.

New

York:

Churchill NA, 1982; A.

Livingstone;

1990:1032-42

2 Lee M, Berger HW, Fernandez actinomycosis. Mt Sinai J Med. 3 Broquetas J, Arms X, Moreno

1swney
49:136-39

S. Endobronchial
actinomycosis 1985;4:508 Ben-Yehuda and actinoD. with

Pulmonary Microbiol

endobronchial
4 Arber Unresolved mycosis. N,

involvement.
Breuer pneumonia R,

Eur

J Cliii

despite persistent severe wheezing. Arterial blood gas values were as follows: pH, 7.40; PaO,, 136 mm Hg; and PaCO2, 38 mm Hg on Flo, 0.4. The airway resistance, which was measured under controlled ventilation with the square-wave flow pattern with endinspiratory pause, was 25 cm H,OfLJs. As the severe wheezing
persisted, through several aT-piece ventilatory andPSV 0, 5, modes, 1#{128}, spontaneous

Berkman N, Okon due to endobronchial

E,

breathing

lipoma M,

Eur
C,

Resplr Marmno

10, and 15 cm

1989;
M,

2:794-96
Lb R, Eur Cornetti Respir 1988; J P Primary Luzi 1:670-71

5 Miracco
endobronchial

actinomycosis.

in random order. Each mode was pattern variables, including auto-PEEP, of use ofeach mode.
PSv 0
,-

used
were

H2O, were employed for 10 mm, breathing and

measured at the end

-.-...-

The Effect
Ventilation

of Pressure
on AUtO-PEEP

Support
in a

(L/S)

Patient
Hiroaki Minoru We lbkioka,
Kinjo,

with Asthma*
M.D.; SeikO

(cmH,O)

Saito, M.D.;
Kosaka,

Shinsei
M.D.

Saeki,

M.D.;
(cmHO)

M.D.;

and Futaini

report

the effect of pressure

in a patient of auto-PEEP

on auto-PEEP a high level

through

a T-piece.

and inspiratory

support ventilation (PSV) with asthma. The patient showed during spontaneous breathing PSV effectively decreased auto-PEEP muscle effort with increasing levels of PSV.
(Chest 1992; 101 :285-86)
VT tidal vol-

151iIILLLLLIi

(cmHO)

]j_jLJjLj

.
:.:
-

(cmHO)

TE

expfratory

time; VE

minute

ventilation;

PSv
(L1S)

10

-r--r-

ume

uto-PEEP
nary disease

in patients
receiving

with

chronic mechanical

obstructive ventilation

pulmois a well(cmH,0)

described trauma

Auto-PEEP may potentiate barnhemodynamic consequences of dynamic hyperinflation. Therefore, the auto-PEEP level should be minimized by changing ventilatory mode or ventilator settings. To our knowledge, however, there have been no reports ofauto-PEEP in patients with asthma who
the Department of Anesthesiology and Besuscitology, University Medical School, Okayama,Japan. Reprint requests: Dr.lbkiOka, Department ofAnesthesiology, !PZflW University Medical School, 2-5-1 Shikata-cho, Okapzma,Ja
)rama 700

phenomenon.14 and deleterious

(cmH)

-a
500ms PSv Paw Peso

= Pressure support ventilation = airway pressure = esophageal pressure

flow, airway pressure, and support ventilation at 0, Auto-PEEP and fluctuation at pressure support ventilation 5,

5Fmm

Oka-

Okapan

Ficuiuz 1. Continuous recordings of esophageal pressure during pressure and 10cm H20 in a patient with asthma. ofesophageal pressure were minimal

10 cm H20.
I 101 I I I JANUARY,

CHEST

1992

285

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Table

1 -Ventitatory

Thtterns

and

a T-Piece
T-piece

and

Auto-PEEP Pressure
PSV

during

Spontaneous

Breathing

through

Support
0

Ventitation
PSV 6.42 5 PSV 6.70 10 PSV 7.26 15

Minute
Tidal

ventilation, volume, ml time,

cm

Llmin

5.02

4.95

224
22.4

Respiratoryrate,breathspermin Expiratory Auto-PEEP,

230 21.5
1.57 13

318
20.2 1.71 10

353 19.0
1.83 6

473 15.4
2.06 7

s
H,O

1.43 11

iPeso,
*PSV negative

cm H5O
0, 5, 10, inspiratory 15=pressure esophageal support ventilation pressure

22
at from 0, 5, 10,

20
15 H,O; cm pressure iPeso esophageal

14 pressure effort.

8 as calculated by subtracting

9 maximal

esophageal

at the inspiratory of start

Flow
flowmeter

and

airway

pressure
Minato,

were
Osaka,

measured
Japan) and

using
a

a hot
differential

wire

(RM-300,

pressure transducer (MP-45, Validyne, Sun Valley,Idaho), respeclively. Tidal volume (VT) and minute ventilation (VE) were determined by integrating the flow signal,and respiratory frequency (1) and expiratory time (FE) were obtained from flow records. Esophageal pressure was measured with a cathetei.tipped transducer

and hypotension were not observed. these breathing pattern variables were recorded, ventilation at PSV 10 cm H20 was continued until the next day, when ventilator Barotrauma After use was gradually discontinued. DIsCussIoN

in auto-PEEP is also very effective in decreasof breathing. When auto-PEEP is present, intrathoracic pressure is positive at end-expiration. Therefore, the patient must develop additional pressure to trigger the ventilator,i0 which piaces a substantial burden on the (12CT, Gaeltec, Scotland). The catheter was properly positioned inspiratory muscles. The effective trigger sensitivity of the using the occlusion test that has been described previously. Autodemand valve is the sum ofthe set value and the auto-PEEP PEEP was determined as a negative deflection esophageal in level. In this case, PSV caused a decrease in phasic changes pressure from the start ofinspiratory effort to the onset of inspiratory flow in esophageal pressure, which facilitated a decrease in With increasing PSV level, 1E and VT increased and f decreased inspiratory muscle effort during PSV. (Table 1). Auto-PEEP was highest at PSV 0 cm H2O and lowest at In conclusion, PSV effectively decreased auto-PEEP in PSV 10 cm H20 (Fig 1). The phasic changen esophageal i pressure this patient with asthma. However, further studies in more during tidal breathing was also minimal at PSV 10 cm H2O. patients with asthma are required before more definitive
conclusions can be drawn. REFERENCES positive end expiratory pressure in patients with airflow obstruction. Am Rev Respir Dis 1982; 125:166-70 2 Rossi A, Cottfried SB, Zocchi L, Higgs BD, Lennox 5, Calverley PMA, et ad. Measurement of static compliance of the total respiratory system in patients with acute respiratory failure duringmechanical ventilation. Am Rev Bespir Dis 1985; 131:672-

useful asthma. A decrease ing the work

very

in

decreasing

auto-PEEP

in

patients

with

1 Pepe

PE,

Marini

JJ.

Occult

mechanically

ventilated

The level of auto-PEEP during mechanical ventilation depends on the resistance and compliance of the total respiratory system, TE, and YE (calculated from VT and f). Auto-PEEP decreases as YE decreases or TE increases. In 77 our patient, an increase TE during in PSY contributed to a 3 Fleury B, Murciano D, ihiamo C, Aubier M, Pariente R, Milicdecrease in auto-PEEP, despite an increase VT. However, in Emili J. Work of breathing in patients with chronic obstructive a PSV level of 15 cm H20 did not decrease auto-PEEP any pulmonary disease in acute respiratory failure. Am Rev Bespir more than a PSV level of cm H20 did. This plateau 10 of Dis 1985; 131:822-27 4 Baydur A, Behrakis PK, Zin WA, Jaeger M, Mihc-Emili J. A auto-PEEP might be due to the markedly increased T at V
PSV
VT, 320

balloon technique. Am Rev Respir Dis 1982; 126:788-91 level of PSV patients in M, Goldaberg P, Milic-Emili J, Goftfried SB. with asthma may be determined as that which provides the 5 Petrof BJ, Legare Continuous positive airway pressure reduces work of breathing minimal level of auto-PEEP Brochard et al have reported and dyspnea during weaning from mechanical ventilation in that in patients recovering from acute respiratory failure, severe chronic obstructive pulmonary disease. Am Rev Respir auto-PEEP was significantly decreased 1.5 cm H20 during to Dis 1990; 141:261-89 ventilation at PSV 10 cm H20 and to0.9 cm H20 during 6 HaluszkaJ, Chartrand DA, GrassinoAE, Milic-EmiliJ. Intrinsic ventilation at PSV 15 cm H20 as compared with auto-PEEP PEEP and arterial Pco, in stable patients with chronic obstrucof 2.7 cm H20 during PSV 0 cm H20. Although the level of live pulmonary disease. Am Rev Respir Dis 1990; 141:1194-97 L, HaifA, Lorino H, Lemaire F. Inspiratory pressure auto-PEEP in their patients was not high, their results are 7 Brochard support prevents diaphragmatic fatigue during weaning from consistent with ours. mechanical ventilation. Am Rev Respir Dis 1989; 136:513-21 In patients with asthma, auto-PEEP increases the risk of 8 Cay PC, Rodarte JR, Hubmayr RD. The effect of positive barotrauma because of hyperinflation. Externally applied expiratory pressure on isovolume flow and dynamic hyperinflaPEEP has been reported to decrease auto-PEEP in patients tion in patients receiving mechanical ventilation. Am Rev Respir with chronic obstructive pulmonary disease.2.589 However, Dis 1989; 139:621-26 external PEEP may increase the total PEEP level and 9 Smith TC, Marini JJ. Impact of PEEP on lung mechanics and exacerbate dynamic hyperinfiation, despite a decrease in work of breathing in severe airflow obstruction. J Appl Physiol auto-PEEP, because of regional differences in limitaflow 1988; 10 Marini 66:1488-99

15 cm H2O, which was greater ml (7 mI/kg). The optimal

than

the

patients normal

simple

method

for

assessing

the

validity

of

the

esophageal

tions.9#{176} Therefore, carefully in patients

286

external PEEP with asthma.

should be In contrast,

used very PSV may

be

JJ. Should PEEP be Rev Respir Dis 1989; 140:1-3

Pvusswe Support !ntIlation

used

in airflow

obstruction?

Am

Effect

on AUtO-PEEP

(Tokkka

etaQ

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The effect of pressure support ventilation on auto-PEEP in a patient with asthma. H Tokioka, S Saito, S Saeki, M Kinjo and F Kosaka Chest 1992;101; 285-286 DOI 10.1378/chest.101.1.285 This information is current as of September 21, 2010
Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/101/1/285 Cited Bys This article has been cited by 2 HighWire-hosted articles: http://chestjournal.chestpubs.org/content/101/1/285#related-urls Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.

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