Features of open lung concept in respiratory therapy of severe community-acquired pneumonia
Background. This article describes a clinical case of severe community-acquired pneumonia. Materials and methods. Sixty-seven-year old female patient was hospitalized to the intensive care unit with severe bilateral community-acquired pneumonia (CRB65 — 4 points, SMART-COP — 6 points, SpO2 = 78–80 %, paO2 — 40 mmHg, pCO2 — 95 mmHg, pH — 7.25; PaO2/FiO2 = 190 mmHg). Intensive care was started immediately. Hemodynamic parameters were stable. Patient was intubated after adequate preoxygenation (NIV CPAP = 8 сmH2O, FiO2 = 80 %). Sedation and myorelaxation continued for 48 hours. Antibacterial therapy and enteral feeding — according to protocol. Unrecruitable lungs were detected after mechanical ventilation started (PCV, p. control = 14 cmH2O, PEEP = 10 cmH2O). High PEEP levels (10 cmH2O) caused deterioration of lung compliance and SpO2. Recruitment maneuvers were ineffective. After that, adaptive support ventilation (%MV = 170 %) mode and lower levels of PEEP (5–6 cmH2O) were used. Patient was in supine position for first 24 hours of respiratory therapy. The next day we used prone position. Results. Adaptive support ventilation, lower PEEP levels and prone position improved patient’s oxygenation rates and respiratory properties of lungs. Conclusions. Selection of the optimal level of PEEP is an important stage of respiratory therapy in patients with unrecruitable lungs. Incorrect adjustment of mechanical ventilation parameters can significantly impair treatment results. Adaptive, intellectual modes of ventilation can be effective in the treatment of severe pneumonias.
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