Time controlled adaptive ventilation™ as conservative treatment of destroyed lung: an alternative to lung transplantation

BMC Pulmonary Medicine

J. Han. J. Meeder¹  Malou Janssen¹  Corstiaan A. den Uil²  Leonard Seghers³ 

[1] Department of Intensive Care Medicine, Erasmus MC, University Medical Center, Dr Molewaterplein 40, Room Rg 626, 3015 GD, Rotterdam, The Netherlands;Department of Intensive Care Medicine, Erasmus MC, University Medical Center, Dr Molewaterplein 40, Room Rg 626, 3015 GD, Rotterdam, The Netherlands;Department of Cardiology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands;Department of Intensive Care Medicine, Maasstad Hospital, Rotterdam, The Netherlands;Department of Pulmonary Medicine, Transplant Center, Erasmus MC, University Medical Center, Rotterdam, The Netherlands;

关键词: Acute respiratory distress syndrome;    Bronchopleural fistula;    Destroyed lung;    Lung protective ventilation;    Time-controlled adaptive ventilation;    Veno-venous extracorporeal membrane oxygenation;   

DOI  :  10.1186/s12890-021-01545-z

来源: Springer

【 摘 要 】

BackgroundAcute respiratory distress syndrome (ARDS) often requires controlled ventilation, yielding high mechanical power and possibly further injury. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be used as a bridge to recovery, however, if this fails the end result is destroyed lung parenchyma. This condition is fatal and the only remaining alternative is lung transplantation. In the case study presented in this paper, lung transplantation was not an option given the critically ill state and the presence of HLA antibodies. Airway pressure release ventilation (APRV) may be valuable in ARDS, but APRV settings recommended in various patient and clinical studies are inconsistent. The Time Controlled Adaptive Ventilation (TCAV™) method is the most studied technique to set and adjust the APRV mode and uses an extended continuous positive airway pressure (CPAP) Phase in combination with a very brief Release Phase. In addition, the TCAV™ method settings are personalized and adaptive based on changes in lung pathophysiology. We used the TCAV™ method in a case of severe ARDS, which enabled us to open, stabilize and slowly heal the severely damaged lung parenchyma.Case presentationA 43-year-old woman presented with Staphylococcus Aureus necrotizing pneumonia. Progressive respiratory failure necessitated invasive mechanical ventilation and VV-ECMO. Mechanical ventilation (MV) was ultimately discontinued because lung protective settings resulted in trivial tidal volumes. She was referred to our academic transplant center for bilateral lung transplantation after the remaining infection had been cleared. We initiated the TCAV™ method in order to stabilize the lung parenchyma and to promote tissue recovery. This strategy was challenged by the presence of a large bronchopleural fistula, however, APRV enabled weaning from VV-ECMO and mechanical ventilation. After two months, following nearly complete surgical closure of the remaining bronchopleural fistulas, the patient was readmitted to ICU where she had early postoperative complications. Since other ventilation modes resulted in significant atelectasis and hypercapnia, APRV was restarted. The patient was then again weaned from MV.ConclusionsThe TCAV™ method can be useful to wean challenging patients with severe ARDS and might contribute to lung recovery. In this particular case, a lung transplantation was circumvented.

【 授权许可】

CC BY