Article, Respiratory Medicine

Supine chest compression: alternative to prone ventilation in acute respiratory distress syndrome

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American Journal of Emergency Medicine

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Supine chest compression: alternative to prone ventilation in acute respiratory distress syndrome?

Abstract

Prone ventilation is usually used for severe acute respiratory distress syndrome. We applied an alternative method to prone position. We described 2 cases of trauma where prone position could not be done. Chest wall compression was performed by 2-kg weight in front of the chest wall bilaterally while the patient was in a supine position. Respiratory mechanics work to improve oxygenation almost as same as the mechanism proposed for prone position without any major adverse effects and serious complications. We suggest a larger randomized study to determine the efficacy and also to find out the optimum weight required to compress the chest.

Prone ventilation commonly reserved for severe Acute respiratory distress syndrome requires additional experienced staff and is associated with increased need of sedatives and Muscle relaxants. Certain situations such as Intracranial hypertension, cervical spine fracture, open abdomen, and severe hemodynamic instability do not allow proning. After obtaining consent, we wish to report 2 such cases where we used a new approach to improve oxygenation in supine position without any complications.

A 34-years-old man was admitted to our emergency department with polytrauma (head injury, cervical spine injury, blunt trauma in the chest and abdomen) in an unconscious state. We secured airway with videolaryngoscope, keeping Philadelphia neck collar in situ. Immediate resuscitation for hypovolemic shock was not able to improve the patient’s hemodynamics. Focused assessed sonography for trauma was inclusive. We shifted him to the operation theater immediately in view of hypotension. Exploratory laparotomy did reveal great findings. Rectus sheath was kept opened, and a “bogota bag” was applied in the abdomen. Postoperatively, he was admitted to the intensive care unit with vasoactive drugs infusion. He developed severe ARDS (PaO2/ fraction of inspired oxygen [FIO2] b 100). Conventional ventilation with a pressure-controlled ventilation (PCV) mode failed to improve oxygen- ation. Inverse ratio PCV and airway pressure release ventilation mode were also tried but did not succeed. Considering proning as an unsafe method, we applied a new concept to compress the anterior chest wall by a 2-kg weight material on each side of chest (Fig. 1) after taking consent. Saturation started improving within 1 hour of chest wall compression. Arterial blood gas analysis (ABG) done every 4 hours was

? Author’s contributions: Sukhen Samanta: concept, case conduction, and manu- script writing; Sujay Samanta: concept and manuscript writing; Kapil Dev Soni: manuscript editing.

suggestive of improving Partial pressure of oxygen in blood/Fractional inspired oxygen concentration PaO2/FiO2 ratio without increasing arterial PaCO2. After 16 hours of Continuous chest compression, the required FIO2 was reduced from 100% to 60. After 3 days, he improved in such a state that he could be weaned from ventilator gradually and ultimately extubated on day 7.

A 45-year-old man was admitted in the ED because of maxillofacial injury with head injury. Computed tomographic scan of the brain showed diffuse Brain edema. He aspirated blood as well as developed severe ARDS. Diffuse brain edema was treated with manitol and frusemide. Conventional ventilation with positive end-expiratory pressure up to 12 cm H2O followed by inverse ratio in PCV came out unfruitful in improving PaO2. The airway pressure release ventilation mode was also not giving consistent improvement in oxygenation. We applied the same method by using 2-L saline bags one on each side (Fig. 2). Here also, we observed significant improvement in oxygen- ation within 6 hours; FIO2 was drastically reduced from 100% to 60% within 12 hours of chest compression.

Recruitments of the dorsal and basal lung with more homogenous distribution of ventilation and perfusion in all lung areas, especially in the major dorsal area, are the most probable causes of increased oxygenation in the supine chest compression than in supine alone. This is partly similar to proning methods. All possible hypothetical mechanisms need to be proved by experimental and clinical studies. The ventral part (sternal) of chest has more freedom of movement than the stiff dorsal part (vertebral) [1]. The inhomogenesity is further more in the supine position causing more ventilation toward the ventral lung areas in paralyzed subjects with ARDS [2]. In the supine chest compression position, movement of the more compliant part (ventral part) becomes impeded by weight on chest. This results in net reduction of the compliance of the ventral thoracic cage. This causes, overall, even more regional (dorsal and ventral) distribution of ventilation resulting in possible relatively higher ventilation toward the dorsal lung (area with higher perfusion). This results in better ventilation perfusion matching overall. More alveoli reach toward the ideal ventilation perfusion ratio, that is, V/Q ? 1, causing improve- ment in oxygenation. Diaphragmatic wall compliance as a whole remained almost the same in supine as well as supine chest compression state, causing more ventilation in the area with possible less basal lung collapse.

Prone ventilation is commonly used in severe ARDS when

oxygenation cannot be maintained by different conventional venti- lation methods and optimizing hemodynamics. Overall, more ho- mogenous distribution of ventilation and perfusion resulting in better V/Q matching seems to be one of the most probable causes of

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Fig. 1. Case 1: patient with severe ARDS in a supine position with a 2-kg weight iron bar

in front of the chest bilaterally. Fig. 2. Case 2: patient with severe ARDS in a supine position with 2-L water bags in front of the chest bilaterally.

increased oxygenation in the prone position. Prone ventilation was neither free of cost nor completely safe; it required additional experienced staff and was associated with an increase in pressure ulcers, high sedation needs, muscle relaxants, and ventilator discon- nection. Supine positioning allows access to vital structures, facilitates catheter placement, allows the patient to face caregivers and family, and avoids potential pressure-related complications such as ocular injury, jugular vein compression, and skin ulceration at points of increased pressure (eg, the nose, chin, or knees). In both the cases here (refractory ARDS), proning is contraindicated, and conventional ventilation approach and optimizing measures failed. Hence, we used our new technique after taking informed consent. In this method, oxygenation improved significantly, reflected in clinical and labora- tory parameters. It will require experimental animal studies to prove the mechanisms. Studies are also required to determine the optimum weight needed for maximum improvement in oxygenation in patients with severe ARDS. More randomized control trials comparing our new technique and traditional proning should also be required to prove its overall impact in clinical scenarios. Our message is to consider supine chest compression as an alternative method to improve oxygenation in patients with severe ARDS when other all optimizing measures fail.

Acknowledgment

The authors thank Dr A.K. Baronia, Professor and Head of the Department of Critical Care Medicine, SGPGIMS, Lucknow, India.

Sukhen Samanta, MD, PDCC Department of Anesthesia & Critical Care (trauma centre) JPNA Trauma Centre, AIIMS, New Delhi 110029, India

E-mail address: [email protected]

Sujay Samanta, MD Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Luckow 226014, India

Kapil Dev Soni, MD

Department of Anesthesia & Critical Care (Trauma Centre)

JPNA Trauma Centre, AIIMS, New Delhi 110029, India

http://dx.doi.org/10.1016/j.ajem.2013.11.014

References

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  2. Gattinoni L, Pelosi P, Crotti S, Valenza F. Effects of positive end-expiratory pressure on regional distribution of tidal volume and recruitment in adult respiratory distress syndrome. Am J Respir Crit Care Med 1995;151:1807-14.