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Changes in Ventilation–Perfusion Mismatch Associated With Inhaled Nitric Oxide in a Patient with Pneumonia That Met Criteria for Acute Respiratory Distress Syndrome
Cambios en la alteración de la ventilación-perfusión asociados a la inhalación de óxido nítrico en un paciente con neumonía que cumplía criterios de síndrome de distrés respiratorio agudo
Anna Sánchez-Corrala,b, Marina García-de-Acilua,c, Manel Santafèa, Oriol Rocaa,c,d,
Corresponding author
a Critical Care Department, Vall d’Hebron University Hospital, Vall d́Hebron Research Institute, Barcelona, Spain
b Departament of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, Bellaterra, Spain
c Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
d Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Color scale adjusted by linear normalization. LL: lower left; LR: lower right; UL: upper left; UR: upper right; ZV: ventilation estimated by EIT; ZQ: perfusion estimated by EIT. (a) Baseline: perfusion reduction in the RL lobe with no changes in ventilation. (b) After 1<span class="elsevierStyleHsp" style=""></span>h of iNO therapy at 10<span class="elsevierStyleHsp" style=""></span>ppm: increase in perfusion in the RL lobe with an improvement in the ventilation–perfusion ratio.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 59-year-old male was admitted to ICU for subarachnoid and lobar hemorrhage. The patient developed acute respiratory failure secondary to aspiration pneumonia that met criteria for acute respiratory distress syndrome (ARDS) with hemodynamic instability requiring noradrenaline at 0.9<span class="elsevierStyleHsp" style=""></span>μg/kg/min. Despite deep sedation and neuromuscular blockade, the patient remained hypoxemic. In supine position, the patient was ventilated in volume-assisted control with a tidal volume of 7.8<span class="elsevierStyleHsp" style=""></span>ml/kg of predicted body weight and PEEP of 10<span class="elsevierStyleHsp" style=""></span>cm of H<span class="elsevierStyleInf">2</span>O at 24<span class="elsevierStyleHsp" style=""></span>breaths/min. In this situation, the plateau pressure was 24<span class="elsevierStyleHsp" style=""></span>cm of H<span class="elsevierStyleInf">2</span>O and the compliance of the respiratory system was 36<span class="elsevierStyleHsp" style=""></span>ml/cm H<span class="elsevierStyleInf">2</span>O. The ratio between partial pressure of oxygen and the fraction of inspired oxygen (PaO<span class="elsevierStyleInf">2</span>/F<span class="elsevierStyleInf">I</span>O<span class="elsevierStyleInf">2</span>) was 84<span class="elsevierStyleHsp" style=""></span>mmHg. Prone positioning could not be performed due to the increased intracranial pressure. Subsequently, respiratory monitoring was complemented with thoracic electrical impedance tomography (EIT). Surprisingly, it revealed a relatively homogeneous ventilation with decreased perfusion of the right lung (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a). In view of these findings, inhaled nitric oxide (iNO) therapy was initiated at 5<span class="elsevierStyleHsp" style=""></span>ppm and increased up to 10<span class="elsevierStyleHsp" style=""></span>ppm. After one hour of iNO therapy at 10<span class="elsevierStyleHsp" style=""></span>ppm, PaO<span class="elsevierStyleInf">2</span>/F<span class="elsevierStyleInf">I</span>O<span class="elsevierStyleInf">2</span> rose to 128<span class="elsevierStyleHsp" style=""></span>mmHg and was associated with a more homogeneous distribution of perfusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>b) measured by EIT. No adverse effects associated with iNO therapy were observed. This case illustrates that iNO can be considered in selected cases of severe hypoxemia. EIT perfusion analysis is a monitoring tool that may be useful in these clinical situations.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1701 "Ancho" => 1667 "Tamanyo" => 186225 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Electrical impedance tomography (EIT) ventilation and perfusion images obtained before (a) and after (b) inhaled nitric oxide therapy at 10<span class="elsevierStyleHsp" style=""></span>ppm. Color scale adjusted by linear normalization. LL: lower left; LR: lower right; UL: upper left; UR: upper right; ZV: ventilation estimated by EIT; ZQ: perfusion estimated by EIT. (a) Baseline: perfusion reduction in the RL lobe with no changes in ventilation. (b) After 1<span class="elsevierStyleHsp" style=""></span>h of iNO therapy at 10<span class="elsevierStyleHsp" style=""></span>ppm: increase in perfusion in the RL lobe with an improvement in the ventilation–perfusion ratio.</p>" ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack572341" "titulo" => "Acknowledgement" "texto" => "<p id="par0010" class="elsevierStylePara elsevierViewall">The authors would like to thank Dr. Caio Morais for his technical assistance in preparing the figures.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/03002896/0000005700000012/v2_202112040821/S030028962030079X/v2_202112040821/en/main.assets" "Apartado" => array:4 [ "identificador" => "21422" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Clinical Images / Imágenes clínicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/03002896/0000005700000012/v2_202112040821/S030028962030079X/v2_202112040821/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S030028962030079X?idApp=UINPBA00003Z" ]
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