Ventilator Management of Bronchopleural Fistula Secondary to Methicillin-Resistant Staphylococcus Aureus Necrotizing Pneumonia in a Pregnant Patient with Systemic Lupus Erythematosus
CCCF ePoster library. Alohali A. Oct 27, 2015; 114755; P81 Disclosure(s): NO relationship with corporate organizations
Ahmed Alohali
Ahmed Alohali
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Abstract
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Topic: Case Report


Ventilator Management of Bronchopleural Fistula Secondary to Methicillin-Resistant Staphylococcus Aureus Necrotizing Pneumonia in a Pregnant Patient with Systemic Lupus Erythematosus



Ahmed Alohali, S. AbuDaff, M. Almaani

Pulmonary and Critical Care Department, King Fahd Medical City, Riyadh, Saudi Arabia | Surgical specilaites, King Fahd Medica City, Riyadh, Saudi Arabia | Pulmonary and Critical Care Department, King Fahd Medical City, Riyadh, Saudi Arabia

Introduction:

Bronchopleural fistula (BPF) is not a frequently encountered complication in intensive care units (ICU) in patients without thoracic surgeries*. BPF poses difficulty in ventilator management especially when it coexsist with Acute Respiratory Syndrome (ARDS).



Objectives: We report a case of a pregnant woman known to have Systemic Lupus Erythematosus (SLE) who developed BPF as a consequence of MRSA necrotizing pneumonia after which she developed ARDS.

Methods:

The patient is a 24-year old pregnant woman G2P1 GA16 week, known case of SLE on Prednisolone 40 mg daily, Azathioprine 50 mg twice daily and Hydroxychloroquine 200 mg twice daily who presented to the emergency department (ED) with fever and productive cough of yellowish sputum of 3 weeks duration.

On physical examination she was febrile with a temperature of 38.4 C. However she was maintaining her oxygen saturation at 96% on room air, with decreased breath sounds on the right infrascapular area.

Her chest x-ray( image1) showed right upper lobe cavitary lesion with a large pneumothorax and pleural effusion. A right sided chest tube was inserted which drained pus. Her chest CT scan (image2) revealed multiple bilateral cavitations (more on the right), moderate right-sided pleural effusion, air space infiltrates, and a right-sided cavitary-pleural communication.

She was admitted to the hospital and started on antibiotics. Later on her sputum and pleural fluid cultures grew Methicillin-Resistant Staphylococcus Aureus. Subsequently, Azathioprine was stopped and Prednisolone tapered off. Fetal ultrasound showed a single viable fetus with normal biometrics.

During her hospital stay she developed shortness of breath and decrease in oxygen saturation requiring mechanical ventilation and ICU admission . Her chest X-Ray(image3) showed right multiple air-filled cavitary lung lesions, right-sided pleural effusion and diffuse air space disease in the left lung.

In the ICU she was fully sedated, paralyzed and supported with vasopresors. Her initial mode of mechanical ventilation was Pressure Control Ventilation (PCV) with total pressure of 34 cmH2O, PEEP 10 cmH2O, rate of 22/minute FiO2 of 100%. She was having significant air leak due to her right BPF. Her arterial blood gas(ABG) showed PH 7.05. PCo2 85 mmHg, PO2 40 mmHg, Bicarbonate 23, oxygen saturation 53 %. Nitric Oxide (NO) was added and her mode of mechanical ventilation shifted to High Frequency Oscillatory Ventilation (HFOV) with a frequency of 4.5 Hz, amplitude 70 cmH2O, mean air way pressure of 26 cmH2O, FiO2 100%. Her gas exchange improved gradually over a few days, NO weaned off and her oxygen requirements decreased. Her mode of ventilation was switched to Controlled Mandatory Ventilation (CMV) tidal volume(TV) of 450 ml, rate 28/minute, PEEP 12 cmH2O, FiO2 45%. ABG on these settings revealed PH 7.35, PCo2 45mmHg, PO2 64mmHg, Bicarbonate 24.

Due to the persistent large air leak the patient put on differential lung ventilation after changing her endotracheal tube to left sided double lumen endotracheal tube. The settings were as follows: left lung CMV TV 200 ml / PEEP 8 cmH2O/ Rate 12/min FiO2 35%; right lung PCV pressure 15 cmH2O / PEEP 4 H2O / FiO2 60% / Rate 12 min. on the above settings the ABG revealed pH7.47, PCo2 36.4 mmHg, PO2 71 mmHg, Bicarbonate 26, oxygen saturation 95%. Air leak improved gradually over 11 days. Differential lung ventilation was then discontinued and her mode of ventilation switched back to CMV with TV 300 ml/ Rate 14 / PEEP 4 cm H2O FiO2 35% and ABG 7.44/ 45/ 138/ 30 patient weaned off mechanical ventilation subsequently. She was transferred to the ward subsequently discharged home



Results: .

Conclusion: .

References:

*Cerfolio RJ. The incidence, etiology, and prevention of postresectional bronchopleural fistula. semin Thorac Cardiovasc Surg. 2001 Jan;13(1):3-7.

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