Advertisement

A Middle-Aged Woman With Viral ARDS and Acute Establishment of Shock on Invasive Mechanical Ventilation

      A female, nonsmoker patient was admitted to the hospital because of fever, nonproductive cough, and worsening dyspnea over a 7-day period. On presentation to the ED, she was in respiratory distress (respiratory rate, 40 breaths/min), with hypoxemia (Table 1), body temperature of 39.2° C, and she was admitted to the general ward. Her laboratory results included the following: hemoglobin, 9.9 g/dL; WBCs, 2,000 cells/μL; platelets, 113,000 cells/μL; total bilirubin, 0.28 mg/dL; prothrombin time, 1.21; activated partial thromboplastin time, 37.9; fibrinogen, 479 mg/dL; lactate dehydrogenase, 1,288 IU/L; C-reactive protein, 20 mg/dL; lactic acid, 2.8 mmol/L. Her chest radiograph showed bilateral alveolar infiltrates. A throat swab turned positive for influenza A (Η1Ν1).
      Table 1Respiratory and Hemodynamic Variables
      Time of Measurements On the ED Before Intubation After Intubation After Intubation
      Respiratory Support Room Air Non Rebreather Mask Mechanical Ventilation

      PEEP: 12 cm H2O
      Mechanical Ventilation

      PEEP: 6 cm H2O
      Respiratory variables
      Pao2, mm Hg 41 60 103 106
      Paco2, mm Hg 24 33 64.5 43
      pH 7.47 7.47 7.16 7.34
      HCO3-, mmol/L 23 30 31 32
      Lactate, mmol/L 0.8 1.7 4.4 3.5
      Hemodynamic variables
      Heart rate, beats/min 98 (SR) 102 (SR) 150 (RBBB) 86 (SR)
      CVP, mm Hg NA 5 19 9
      MAP, mm Hg 74 71 65 67
      Vasopressors, μg/kg/min 0 0 2.2 0.7
      Scvo2, % NA 78 60 75
      Pa-vCO2 NA 2 10 4
      Respiratory and Hemodynamic variables of the patient at four time points:
      1. On presentation in the ED
      2. Just before intubation
      3. Immediately after intubation and mechanical ventilation initiation with PEEP 12 cm H2O
      4. After PEEP de-escalation to 6 cm H2O
      CVP = central venous pressure; DP = driving pressure measured as the difference between Pplat-PEEP; Hco3- = serum bicarbonate levels; MAP = mean arterial pressure; Pa-vo2 = arteriovenous carbon dioxide pressure difference; PEEP = positive end expiratory pressure; Pplat = plateau pressure; RBBB = right bundle brunch block; RR = respiratory rate; Scvo2 = vena caval oxygen saturation; SR = sinus rhythm; Vt = tidal volume
      To read this article in full you will need to make a payment
      Subscribe to CHEST
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Engelke C.
        • Rummeny E.J.
        • Marten K.
        Acute pulmonary embolism on MDCT of the chest: prediction of cor pulmonale and short-term patient survival from morphologic embolus burden.
        AJR Am J Roentgenol. 2006; 186: 1265-1271
        • Zapol W.M.
        • Kobayashi K.
        • Snider M.T.
        • et al.
        Vascular obstruction causes pulmonary hypertension in severe acute respiratory failure.
        Chest. 1977; 71: 306-307
        • Brower R.G.
        • Matthay M.A.
        • et al.
        • Acute Respiratory Distress Syndrome Network
        Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network.
        N Engl J Med. 2000; 342: 1301-1308
        • Brown S.M.
        • Pittman J.
        • Miller III, R.
        • et al.
        Right and left heart failure in severe H1N1 influenza A infection.
        Eur Respir J. 2011; 37: 112-118
        • Vieillard-Baron A.
        • Girou E.
        • Valente E.
        • et al.
        Predictors of mortality in acute respiratory distress syndrome: focus on the role of right heart catheterization.
        Am J Respir Crit Care Med. 2000; 161: 1597-1601
        • Repesse X.
        • Charron C.
        • Vieillard-Baron A.
        Acute respiratory distress syndrome: the heart side of the moon.
        Curr Opin Crit Care. 2016; 22: 38-44
        • Paternot A.
        • Repesse X.
        • Vieillard-Baron A.
        Rationale and description of right ventricle-protective ventilation in ARDS.
        Respir Care. 2016; 61: 1391-1396
        • Vieillard-Baron A.
        • Matthay M.
        • Teboul J.L.
        • et al.
        Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation.
        Intensive Care Med. 2016; 42: 739-749
        • Jardin F.
        • Vieillard-Barron A.
        Is there a safe plateau pressure in ARDS? The right heart only known.
        Intensive Care Med. 2007; 33: 444-447
        • Vieillard-Baron A.
        • Jardin F.
        Why protect the right ventricle in patients with acute respiratory distress syndrome?.
        Curr Opin Crit Care. 2003; 9: 15-21