0
Critical Care |

Patients With ARDS and Elevated BMI May Need Higher Than Conventional PEEP to Prevent Atelectasis

Charles Hunley*, MD; Rumi Khan, MD; Rakesh Gupta, MD; Timothy Jones, MD; Edgar Jimenez, MD
Author and Funding Information

Orlando Health, Orlando, FL


Chest. 2012;142(4_MeetingAbstracts):351A. doi:10.1378/chest.1390185
Text Size: A A A
Published online

Abstract

SESSION TYPE: Critical Care Student/Resident Case Report Posters II

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The current conventional practice of ARDSNet guided vent management strategy does not have any special consideration for morbidly obese patients. These 2 cases show that morbidly obese patients may need significantly more PEEP than we use in our conventional practice.

CASE PRESENTATION: Patient 1: 69 year old vent dependent male with a BMI of 52 transferred to a tertiary hospital for worsening respiratory failure secondary to pseudomonas pneumonia, and renal failure. Hypoxemia worsened despite antibiotics and renal replacement therapy. Despite full vent support with 100% FiO2 and PEEP 22 patient had difficulty in maintaining oxygenation. The ABG at this point was 7.18 PaCo2 59 PaO2 70. An esophageal balloon was inserted to measure trans-pulmonary pressure (PtpPEEP). Initial trans-pulmonary pressure on PEEP of 22 was - 7 cm of H2O. PEEP was titrated up to 32 to achieve a trans-pulmonary pressure of 0 to +1. Twelve hours later, on ventilator setting with higher PEEP of 32, ABG improved to 7.20/58/152. 24 hours latter, pO2 increased to 354 with no significant changes to pH or PaCO2. Despite improvement in PaO2/FiO2, family decided to withdraw life support secondary to patient’s multiple co-morbidities and ventilator dependence. Patient 2: 45 year old female BMI 42 admitted for pneumonia secondary to Influenza and was started on antibiotics and oseltamivir. Patient however became increasing dyspneic with respiratory rate of 45 subsequently requiring intubation and mechanical ventilation. Despite FiO2 90% PEEP 12 patient’s blood gas showed PaO2 54. An esophageal balloon was inserted. Pao2 improved to120 with titration of PEEP to 18 to maintain PtpPEEP between 0 and +1. Over the next 48 hours PEEP was titrated up to 21 cm H2O and FiO2 eventually decreased to 40%. PEEP was later titrated to 10 and patient was extubated successfully on day 4 of mechanical ventilation.

DISCUSSION: With Morbid obesity it is known that decreased external compliance increases intrapleural pressures and creates negative trans-pulmonary pressures. To counter the more negative trans-pulmonary pressure the greater PEEP is needed. The current conventional practice of ARDSNet guided vent management strategy does not have any special consideration for morbidly obese patients. These cases show that morbidly obese patients may need significantly more PEEP than we use in our conventional practice. Esophageal balloon guided measurement of trans-pulmonary pressure in obese patients may be a useful tool in adjusting PEEP to prevent atelectasis and improve oxygenation. It has already been shown that PtpPEEP guided ventilator management has improved oxygenation in general population.

CONCLUSIONS: Patients with ARDS induced refractory hypoxemia and high BMI may specifically benefit from PtpPEEP guided higher PEEP.

1) Talmor D, et al.: N Engl J Med. 2008; 359(20):2095

2) Bernard G: N Engl J Med 2008; 359:2166Acute Respiratory Distress Syndrome Network: N Engl J Med 2000; 342:1301

DISCLOSURE: The following authors have nothing to disclose: Charles Hunley, Rumi Khan, Rakesh Gupta, Timothy Jones, Edgar Jimenez

No Product/Research Disclosure Information

Orlando Health, Orlando, FL

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Figures

Tables

References

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Sign In to Access Full Content

MEMBER & INDIVIDUAL SUBSCRIBER

Want Access?

NEW TO CHEST?

Become a CHEST member and receive a FREE subscription as a benefit of membership.

Individuals can purchase this article on ScienceDirect.

Individuals can purchase a subscription to the journal.

Individuals can purchase a subscription to the journal or buy individual articles.

Learn more about membership or Purchase a Full Subscription.

INSTITUTIONAL ACCESS

Institutional access is now available through ScienceDirect and can be purchased at myelsevier.com.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543