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Respiratory Care |

Noninvasive Positive Pressure Ventilation (NPPV) for Reversal of Diffuse Cerebral Edema From Acute-on-Chronic Hypercapnic Respiratory Failure in Amyotrophic Lateral Sclerosis (ALS)

Amir Tirmizi*, MD
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St. Dominic-Jackson Memorial Hospital, Jackson, MS


Chest. 2012;142(4_MeetingAbstracts):947A. doi:10.1378/chest.1388862
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Abstract

SESSION TYPE: Respiratory Support Posters

PRESENTED ON: Wednesday, October 24, 2012 at 01:30 PM - 02:30 PM

PURPOSE: Present a case report of successful use of NPPV in the treatment of diffuse cerebral edema resulting from severe hypercapnia in ALS.

METHODS: A 52 years old Caucasian female with ALS was admitted to the hospital with poor oral intake, dehydration and urinary tract infection. Patient has been using nighttime bilevel positive airway pressure (BPAP) therapy at home for chronic hypercapnic respiratory failure. Her baseline arterial blood gases (ABGs) on room air showed pH of 7.398, pCO2 of 56.3, pO2 of 75.4 and HCO3 of 33.9. Patient’s symptoms markedly improved over the next three days with intravenous normal saline at 100ml/hr and intravenous ciprofloxacin 400mg every twelve hours. On the fourth day of her hospitalization she developed sudden change in her mental status with increasing lethargy and unresponsiveness and was transferred to ICU.

RESULTS: Emergent CT scan of the head showed diffuse cerebral edema that was later confirmed by MRI. Arterial blood gases on FiO2 32% revealed pH of 7.207, pCO2 of 123.5, pO2 of 84.9 and HCO3 of 48. Patient was placed on continuous BPAP with inspiratory positive airway pressure of 15 cm H2O and expiratory positive airway pressure of 5 cm H2O. Repeat ABGs two hours later showed pH of 7.264, pCO2 of 131.4, pO2 of 103.8 and HCO3 of 58.2. Patient’s status was changed to DNR per family’s request and she was continued with BPAP. Patient’s lethargy resolved next day with reversal of cerebral edema and ABGs showed pH of 7.459, pCO2 of 71.6, pO2 of 215.1 and HCO3 of 49.7. At the time of discharge patient’s mental status was normal.

CONCLUSIONS: Diffuse cerebral edema due to worsening hypercapnic respiratory failure in ALS can be easily reversed by palliative use of noninvasive positive pressure ventilation.

CLINICAL IMPLICATIONS: To my knowledge this is the first case report of use of noninvasive positive pressure ventilation in the treatment of cerebral edema resulting from hypercapnic respiratory failure in a patient with Amyotrophic Lateral Sclerosis.

DISCLOSURE: The following authors have nothing to disclose: Amir Tirmizi

No Product/Research Disclosure Information

St. Dominic-Jackson Memorial Hospital, Jackson, MS

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