Critical Care |

Weaning Inhaled Nitric Oxide in a Patient With Severe ARDS Using Hemodynamic Transesophageal Echocardiography (hTEE) FREE TO VIEW

Craig Ainsworth, MD; Timothy Ori, MD; Timothy Jardeleza, MD
Chest. 2013;144(4_MeetingAbstracts):275A. doi:10.1378/chest.1704667
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SESSION TITLE: Critical Care Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Hemodynamic transesophageal echocardiography is an FDA approved technology that uses thin, flexible, probes that enable intensivists to visualize cardiac function and assess volume status for up to 72 hours per probe. This minimally invasive technique can be used to assess the response of the heart as vasopressors, inotropes and vasodilators are titrated to optimal dose.

CASE PRESENTATION: We present the case of a 56 year old male with a history of carcinoma of the tongue that was witnessed aspirating tube feeds on a medical ward. He was intubated for hypoxic respiratory failure. Despite bronchoscopic removal of aspirate, low tidal volume ventilation, then airway pressure release ventilation, the patient developed worsening hypoxia. Inhaled nitric oxide (iNO) therapy was initiated with improvement in the PaO2/FiO2 ratio from 78 to 166 mmHg. Peak dose of iNO was 80 ppm, and following improvement in oxygenation over the next 2 days, we began to wean ventilator support and the iNO therapy. We decreased the iNO dose by 10ppm every 2-4 hours. When the patient was weaned from 10ppm to off, he experienced a drop in blood pressure and oxygen saturation. He was given a bolus of fluid and iNO was resumed at 20ppm with a concomitant improvement in his hemodynamics and oxygenation noted. If the cessation of iNO was responsible for his decompensation, then stopping iNO had caused enough of an elevation in pulmonary artery pressure to cause right ventricular dysfunction. This would cause left ventricular dysfunction, a decrease in cardiac output, and the hypotension and hypoxia we observed. We inserted an hTEE probe and assessed right and left ventricular size and function. Leaving the probe in place, we then stopped iNO therapy and observed for changes. No changes in right ventricular size or function were observed after therapy had been discontinued. We were thus able to confirm that discontinuation of iNO had not been the cause of the patient’s decompensation.

DISCUSSION: The ability to insert the probe and leave it in place facilitated image acquisition and analysis as iNO therapy was discontinued. Given its short half life, we only had to wait a few minutes for the iNO to clear the patient’s system, to be able to observe for any changes. Being able to confirm that iNO was not the culprit, allowed us to change our diagnostic and management strategy and appropriately manage the patient.

CONCLUSIONS: We report the first case of iNO therapy management guided by hemodynamic imaging using an hTEE probe. This new tool has been demonstrated to be easy to insert and can be safely left in place.

Reference #1: Vieillard-Baron, A. et al. A pilot study on the safety and clinical utility of a single-use 72-hour indwelling transesophageal echocardiography probe. Intensive Care Medicine. 2013 Apr; 39(4):629-35.

DISCLOSURE: The following authors have nothing to disclose: Craig Ainsworth, Timothy Ori, Timothy Jardeleza

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