|Respiratory Care Education|
On admission approximately 45 minutes later, his Glasgow Coma Scale score was 14, and he was complaining of right chest pain with dyspnea and hemoptysis. A fractured clavicle and subcutaneous air with decreased breath sounds were noted on the right side. Abdominal tenderness was found. A 32F intercostal drain was inserted in the right side of the chest to relieve a hemothorax and pneumothorax. Within 15 minutes the patientís condition had deteriorated and intubation became necessary. During intubation dark red foam was seen to flow from the larynx. He was manually ventilated with 100% oxygen and 15 cm H2O PEEP with an initial good response. He was subsequently placed on mechanical ventilation with PEEP.
|In the early hours of the next morning, a double lumen tube was placed and differential lung ventilation initiated because of deteriorating gas exchange and increasing air loss from the right chest.|
Two hours later, deteriorating oxygenation required a repeat chest x-ray film. The x-ray revealed a left pneumothorax which was drained using another chest tube.
Resuscitation was continued with fluids and inotrope support, and he maintained an adequate blood pressure and urine output. Later that morning a Swan-Ganz catheter was inserted and positioned in the right pulmonary artery. High pulmonary artery pressures of 60/35 mm Hg were measured with a mean pulmonary artery pressure of 45 mm Hg and a wedge pressure of 24 mm Hg. The cardiac index was satisfactory at 4.1 L/min/m2.
In the afternoon on Day 3, the patient underwent a right thoracotomy which found his right lung to be full of blood with large lacerations in the upper lobe and in the apex of the lower lobe. There was no tracheal or main bronchial tears. The lacerations were cleaned and packed with hemostatic foam. The thorax was closed with three new drainage tubes in addition to the three already in place.
|For the remainder of that day, and the next two days (4 and 5), the patient was maintained on differential lung ventilation with conventional settings to both lungs, but his gas exchange was precarious and the leak from the right lung continued unabated.|
This change immediately brought about a dramatic improvement in both oxygenation and CO2 removal, such that in 3 hours his PaCO2 fell from 75 to 59 mmHg, and his PaO2 rose from 68 to 95 mmHg.
This management was continued with steadily improving gas exchange until day 11 when low frequency ventilation was attempted on the right lung but was abandoned because of falling PaO2 and rising PaCO2. The double-lumen tube was changed for the second time because of blockage by secretions. Later the patient was successfully changed back to conventional ventilation via a single-lumen tube to both lungs.
On day 17 direct laryngoscopy revealed laryngeal edema only. A tracheotomy was performed and ventilatory weaning begun.
On day 19 a tracheal aspirate, taken on day 15, was reported to be growing Enterobacter organisms and antibiotic therapy was started and continued for 10 days.
On day 21 the drainage from the right intercostal drains had become frankly purulent and was also growing Enterobacter organisms.
On day 31 he was extubated and discharged well on day 44.
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Good Question - Although it's not clear from the information presented, the patient started out with 500 ml to each lung when the double lumen tube was initially placed. As the leak on the right persisted, the right tidal volume was decreased as the left tidal volume was increased. The case report wasn't clear on all the ventilator settings, unfortunately. (It's sometimes difficult to go back and find all the information you need.) There is a limit however, as to how high the volume could go to the good lung without creating high airway pressures. Volume controlled ventilation simply wasn't working in this patient, and the double lumen tube did eventually allow HFPPV to the right lung which improved oxygenation.
Oh, I see. Thank you