COVID-19 Prevention and Control Recommendations for the ICU

Robert A. Raschke, MD¹

Sandra L. Till, DO²

Henry W. Luedy, MD¹

¹HonorHealth Scottsdale Osborn Medical Center

²Banner University Medical Center-Phoenix

Phoenix, AZ USA

Editor’s Note: We are planning on presenting a case of COVID-19 from Osborn as our case of the month for April. The authors felt we should publish preliminary recommendations now early in the COVID-19 pandemic. The recommendations are not necessarily evidence-based but are based on recent experience and published experience with previous coronavirus outbreaks such as SARS.

Background:

• COVID-19 is likely somewhat more infectious than influenza (R value in 2-3 range), and can be transmitted by asymptomatic/presymptomatic persons.
• COVID-19 is already in the community and likely being spread from person to person, Therefore, not all COVID-19 patients will present with a recognized exposure history. Furthermore, fever and pneumonia are not universally present.
• As of this writing, >3,300 healthcare workers have been confirmed infected globally with 6 deaths.
• Testing is currently extremely limited in the US with only a minority of potential cases having been tested at this time. This will likely improve over the next few days to weeks. True incidence likely much higher than reported rates of “confirmed COVID-19”.
• About 15% of patients with confirmed COVID-19 have severe disease and 5% require ICU level care. Mortality rates of approximately 1-2% may be confounded by undertesting, but is currently more than 10 times higher than that of influenza (approx. mortality of 0.05-0.1%) (1).

Infectious disease control issues in the ICU. We recommend droplet, contact and standard precautions when seeing any patient presenting with symptoms of acute upper or lower respiratory tract infection of unknown etiology, regardless whether they meet full CDC criteria for COVID-19 testing. 

Studies during the SARS epidemic showed that intubation, bag-mask ventilation, non-invasive ventilation and tracheostomy procedures were all associated with increased transmission of SARS to healthcare workers (2).

Code arrest. We recommend aerosol, contact and standard precautions and eye protection for all code team members for all codes - regardless of whether COVID-19 is suspected. There is no time in a code to determine the likelihood of the patient having COVID-19, and bag-masking and intubation will aerosolize the patient’s respiratory secretions. A HEPA filter should be placed between the patient and the bag mask to reduce aerosolization of viral particles into the atmosphere.

Elective or semi-elective endotracheal intubation of patients with possible or confirmed COVID-19. If available, powered air-purifying respirators (PAPR) using P100 HEPA filters (filter >99.97% of 0.3 um particles) should be considered over N-95 (filter 95% of 5 um particles) masks during this high-risk procedure based on prior reports of SARS CoV-1 transmission to healthcare workers wearing N95 masks (3). PAPR protects the entire head and neck of the HCW, but requires additional training on donning/duffing.

If unable to wear PAPR, we recommend N95 masks, gowns and gloves, with googles instead of open face shielded masks. Aerosolized particles are more likely to pass around shields into eyes during these high-risk procedures. We also recommend hats and foot protection.

The smallest number of personal required to safely perform the intubation should be present in the room. Fiberoptic laryngoscopy may be preferred over direct laryngoscopy to reduce exposure to aerosolized particles. Once intubated, a HEPA filter should be placed on the exhalational limb of the ventilator.

Non-invasive ventilation and high-flow nasal oxygen. Non-invasive ventilation and high-flow nasal oxygen likely increase the infectivity of COVID-19 by aerosolizing the patient’s respiratory secretions. Consideration should be given to early intubation in patients under investigation or confirmed for COVID-19 (4).

Visitors should not be allowed inside the rooms of such patients except under extreme circumstances and with one-on-one supervision to assure proper use of PPE and handwashing.

Furthermore, we think it is prudent to employ PPE in the rooms of all patients receiving these therapies, since patients with COVID-19 may present atypically (as in the Osborn case). The doors of their rooms should be kept closed, unnecessary traffic in the room reduced, and droplet contact and standard PPE considered, even in patients in whom COVID-19 is not suspected. (This approach has the downside of consuming PPE that might later be in short supply, but has the upside of preserving healthcare workers who also might later be in short supply).

References

1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020 Feb 24. [Epub ahead of print]. [CrossRef] [PubMed]
2. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. [CrossRef] [PubMed]
3. Cheng VC, Chan JF, To KK, Yuen KY. Clinical management and infection control of SARS: lessons learned. Antiviral Res. 2013 Nov;100(2):407-19. [CrossRef] [PubMed]
4. Zuo MZ, Huang YG, Ma WH, Xue ZG, Zhang JQ, Gong YH, Che L; Chinese Society of Anesthesiology Task Force on Airway Management. Expert recommendations for tracheal intubation in critically ill patients with noval [sic] coronavirus disease 2019. Chin Med Sci J. 2020 Feb 27. [CrossRef] [PubMed]

Cite as: Raschke RA, Till SL, Luedy HW. COVID-19 prevention and control recommendations for the ICU. Southwest J Pulm Crit Care. 2020;20(3):95-7. doi: https://doi.org/10.13175/swjpcc017-20 PDF 

Loperamide Abuse: A Case Report and Brief Review

Jaclyn Leong DO¹

Kava Afu MS-3²

Ella Starobinska MD¹

Michael Insel MD³ 

¹Department of Internal Medicine, ²University of Arizona College of Medicine, and ³Department of Pulmonary and Critical Care

Banner University Medical Center

Tucson, AZ USA 

Case Presentation

A 29-year-old man with unspecified mood disorder, childhood attention deficit hyperactivity disorder, and 2 prior suicide attempts with zolpidem and methadone presented with altered mental status as a transfer from an outside hospital. The patient was found in his truck outside of a grocery store by a bystander who contacted emergency medical services. At the time, he was noted to have seizure-like activity. He had an empty shopping bag in his possession with 14 empty loperamide (Imodium®) bottles, each were supposed to contain 24 tablets. The patient was taken to the nearest medical facility where he was found to be in status epilepticus. After no response to 4 mg intravenous (IV) lorazepam, he was then intubated for airway protection. Propofol infusion was started and a loading dose of levetiracetam 1600 mg IV was administered. Despite medical management, he continued to show evidence of seizure-like activity. Due to the lack of a neurology service at the hospital, the patient was transferred to our academic medical center.

On arrival, patient was intubated, sedated and hemodynamically stable. Sedation was paused to allow a thorough neurologic examination, at which time, he became agitated and was not redirectable. However, he did not exhibit seizure activity. Toxicology service was consulted for suspected loperamide overdose.

Laboratory workup revealed white blood cell count 16,600 µL with neutrophilic predominance (4000-11000), glucose 205 (70- 106 mg/dL), lactic acid of 10 (0.5- 1.7 mmol/L), creatinine kinase 164 (35- 232 IU/L), creatinine 1.39 ( 0.60- 1.50 mg/dL), EGFR 79 (Normal Low >=60). Tylenol and salicylate levels were undetectable. Urine drug screen was negative. Computer tomography (CT) of the head showed no acute intracranial process. CT abdomen/pelvis showed bibasilar airspace consolidations concerning for aspiration pneumonia. Echo revealed left ventricular ejection fraction of 38% with a large-sized apical, septal, anteroseptal, anterior, inferior, posterior, and lateral wall motion abnormality with hypokinesis to akinesis of the segments.

Electrocardiograms (ECG) initially showed QTc and QRS prolongation of 571 ms and 160 ms, respectively. During the initial 24-hours at our hospital, serial EKGs were performed to monitor QTc. Additionally, patient was treated empirically for aspiration pneumonia with ampicillin/sulbactam.

On day two of his hospitalization, his ECG revealed sinus rhythm, with first-degree AV block and QT prolongation greater than 700 ms. Subsequently, torsades de pointes developed, progressing into ventricular tachycardia storm. Several ampules of bicarbonate were administered, and the patient was cardioverted. Dobutamine and magnesium infusions were started and a temporary transvenous pacer was placed with overdrive pacing initiated at 110 bpm. Over the next 24 hours, magnesium and dobutamine were discontinued. The transvenous pacer was removed on hospital day 4 after the patient demonstrated a native rhythm with normal QRS and QT intervals. Levetiracetam was also discontinued, per neurology recommendations. The patient was safely extubated on hospital day 5. He was subsequently evaluated by the psychiatry service who scheduled close follow up after discharge.

Discussion

Loperamide is a nonprescription drug used most commonly to control acute, nonspecific diarrhea, as well as chronic diarrhea associated with inflammatory bowel disease. It acts on mu-opioid receptors in the myenteric plexus to reduce peristaltic activity, thus lengthening bowel transit time and lowering volume and frequency of bowel movements (1). In contrast to other opioid receptor agonists, loperamide has poor absorption from the gastrointestinal tract and limited ability to cross the blood-brain barrier (1,2). Consequently, the drug was deemed low risk for physical dependence and abuse and since 1982 has been sold over-the-counter (OTC) (3).

Despite this labeling, there is an increasing number of reports documenting cases of loperamide misuse and abuse (3). It has only recently been discovered that loperamide is being ingested at supratherapeutic doses (>16 mg/day) for its euphoric effects or for the relief of opioid withdrawal symptoms (3,4). In 2013, online reports of recreational loperamide use at doses of 70-100mg began circulating (3). In the following three years, a 71% increase of loperamide-associated presentations to drug and poison control agencies was reported (3,6).

As a result, the cardiotoxic effects of this drug have come to light, particularly QT-prolongation and QRS- widening (3). At supratherapeutic plasma concentrations, loperamide causes a blockade of the human ether-a-go-go-related gene (hERG) cardiac potassium channel with high affinity, delaying repolarization of the cardiac myocytes and affecting QT-interval and QRS complex (5). Life-threatening dysrhythmias ensue, accounting for the increasing rate of deaths associated with loperamide overdose and toxicity (3). Reports of loperamide-associated cardiac toxicity have increased greatly in number over the past few years and include: at least 21 individual published case reports of loperamide cardiotoxicity, including one published in SWJPCC (3,7); 48 cases of serious loperamide-associated cardiac events, identified in the FDA Adverse Event Reporting System database; and 22 cases of patients found dead with elevated plasma concentrations of loperamide (3).

Loperamide is just one of an increasing number of OTC drugs with potential abuse because of the stimulant or sedative effects. Other OTC drugs commonly known for abuse are dextromethorphan, pseudoephedrine, phenylephrine, diphenhydramine and oxybutynin especially among teenagers, however, loperamide is a less commonly known drug for its opioid abuse. It is important for physicians to be aware of this increasing risk of abuse and significant life-threatening cardiotoxic effects.

References

1. Killinger JM, Weintraub HS, Fuller BL. Human pharmacokinetics and comparative bioavailability of loperamide hydrochloride. J Clin Pharmacol. 1979;19:211-8. [CrossRef] [PubMed]
2. Regnard C, Twycross R, Mihalyo M, et al. Loperamide. J Pain Symptom Manage. 2011;42:319-23.[CrossRef] [PubMed]
3. Wu PE, Juurlink DN. Clinical review: Loperamide toxicity. Annals of Emergency Med. 2017;70:245-52. [CrossRef] [PubMed]
4. Daniulaityte R, Carlson R, Falck R, et al. "I just wanted to tell you that loperamide will work": a web-based study of extra-medical use of loperamide. Drug Alcohol Depend. 2013;130:241-4. [CrossRef] [PubMed]
5. Salama A, Levin Y, Jha P, et al. Ventricular fibrillation due to overdose of loperamide, the "poor man's methadone." J Community Hosp Intern Med Perspect. 2017;7(4):222-6. [CrossRef] [PubMed]
6. Stanciu CN, Gnanasegaram SA. Loperamide, the "Poor Man's Methadone": Brief review. Journal of Psychoactive Drugs. 2017;49:18-21. [CrossRef] [PubMed]
7. Watkins SA, Smelski G, French RNE, Insel M, Campion J. January 2019 critical care case of the month: A 32-year-old woman with cardiac arrest. Southwest J Pulm Crit Care. 2019;18(1):1-7. [CrossRef]

Cite as: Leong J, Afu K, Starobinska E, Insel M. Loperamide abuse: a case report and brief review. Southwest J Pulm Crit Care. 2020;20(2):73-5. doi: https://doi.org/10.13175/swjpcc007-20 PDF

Single-Use Telescopic Bougie: Case Series

Evan Denis Schmitz MD

La Jolla, CA USA

Abstract

AIROD^TM is a single-use telescopic bougie that is small enough to fit into a pocket. AIROD^TM is sterile and can be expanded in hast when needed, saving precious seconds, while attempting to intubate a patient. The non-malleable bougie is able to overcome the compressive force of the oropharyngeal tissue improving the view of the vocal cords and facilitating advancement of an endotracheal tube into the trachea along with a laryngoscope. This series reports four cases of successful first pass intubation with the AIROD^TM.

Introduction

There are approximately 50 million intubations performed a year with 1/3 of those occurring in the USA. A multicenter registry of ED intubations, reporting data from 2002-2012, found that approximately 12% of intubations resulted in adverse intubation-related events such as death (1). In order to reduce the likelihood of adverse events it is imperative that the first attempt at endotracheal intubation is successful (2). Despite increasing adoption of expensive video laryngoscopy first-attempt intubation success rates are only 85% (1). The BEAM trial reported a 96% success rate in first-attempt intubation of a difficult airway with a bougie vs only 82% with endotracheal tube + stylet (3).

AIROD^TM was designed to aid in the advancement of an endotracheal tube past the vocal cords with the use of a laryngoscope (Figure 1).

Figure 1. Single-Use Telescopic Bougie in the closed (A) and extended (B) position with an endotracheal tube loaded at the distal end.

AIROD^TM can also improve the view of the vocal cords during intubation by displacing oropharyngeal tissue. The following case series demonstrates the usefulness of the AIROD^TM: each of the 4 intubations were successful on the first attempt and facilitated by the single-use telescopic bougie without causing any trauma. All intubations were performed by the author.

Case 1

A 70-year-old woman with severe COPD not on home oxygen presented with an oxygen saturation of 70%. She was found to have multi-lobar pneumonia predominately in the right upper and middle lobes. Despite bilevel positive airway pressure (BiPAP) therapy her hypoxia worsened, and she required intubation. Inspection of her oropharynx prior to intubation revealed very prominent 1^st incisors as well as canines that were eroded at the roots left worse than right. Multiple black, necrotic molars were noted, right worse than left, with a putrid odor. Her oxygen saturation, despite being on 15L nasal cannula, hovered in the low 90s. In anticipation of a difficult airway the AIROD^TM was prepared by extended the rods and ensuring the rods were in the locked position. A Miller 4 blade was gently inserted past the teeth and into the oropharynx. A grade 2 view (larynx plus the posterior surface of epiglottis) was obtained. This was immediately followed by gentle insertion of the AIROD^TM which was advanced just distal to the vocal cords. An 8.0 endotracheal tube was advanced down the AIROD^TM by the respiratory therapist while the AIROD^TM was held in position. As the endotracheal tube was advanced into the oropharynx, hand position was changed from holding the AIROD^TM to holding the tip of the endotracheal tube while the respiratory therapist held the distal end of the AIROD^TM. The endotracheal tube was then advanced past the vocal cords and into the trachea while the respiratory therapist removed the AIROD^TM with ease. No complications occurred. No trauma occurred to the oropharynx, vocal cords or trachea. The patient was successful ventilated and oxygen saturations improved to high 90s.

Case 2

A61-year-old man with severe schizophrenia and acute delirium had a PaO2 of 61 mmHg despite BiPAP 14/6 on 90% fio2 with a minute ventilation of 18 L/min from multi-lobar pneumonia. A Miller 4 blade was gently inserted past the teeth and into the oropharynx. A grade 1 view (whole vocal cords seen; the epiglottis is not seen at all) was obtained. The AIROD^TM was gently advanced 2 cm past the vocal cords followed by an assistant advancing a 7.5 endotracheal tube down the AIROD^TM until grasped, then the endotracheal tube was slid into the trachea while the assistant held the distal end of the AIROD^TM. The AIROD^TM was then removed intact with no evidence of airway trauma.

Case 3

A 54-year-old man with severe coronary artery disease on aspirin and Plavix with a history of a seizure disorder associated with alcohol withdrawal became unresponsive and a code blue was called. He was found to be apneic with oxygen saturation in the 50s. He was stimulated by the hospitalist and woke up. He was transferred to the ICU where he became completely unresponsive again and became apneic. He was immediately ventilated with a bag-valve mask and oxygenation improved to 100%. He then bolted up out of bed and became very combative. Propofol was given and he was laid supine and ventilated with a bag-valve mask. Inspection of his oropharynx revealed a very large tongue, some missing and multiple sharp teeth with mouth opening of only 2 fingerbreadths. There was blood and emesis in his oropharynx that was suctioned. A Miller 4 blade was inserted into the oropharynx but only a grade 4 view (the anterior tip of the epiglottis is seen and encroaching on the view of vocal cords obstructing <50% of view) could be obtained. The AIROD^TM was inserted into the oropharynx in the fully extended and locked position and the proximal tip was used to gently lift the epiglottis exposing the vocal cords and improving the view to a grade 2. AIROD^TM was advanced 2 cm past the vocal cords and an assistant advanced an 8.0 endotracheal tube down the AIROD^TM until it was grasped, and the endotracheal tube was advanced successfully past the vocal cords while the assistant held the distal end of the AIROD^TM. The AIROD^TM was removed intact without any oropharyngeal or vocal cord trauma.

Case 4

A 48-year-old obese who was an alcoholic and a smoker was critically ill with an admission albumin of 0.9 and lactic acid of 9 with multiorgan system failure from an intra-abdominal abscess with septic shock on 15 mcg/min of epinephrine and 25 mcg/min of Levophed. He was obtunded and in acute respiratory failure. The AIROD^TM was pre-loaded with an 8.0 endotracheal tube onto the distal end of the AIROD^TM prior to providing sedation with Etomidate and bag-valve mask ventilation in anticipation of a difficult airway: full beard, mouth opening 2 cm, large tongue, collapse of the walls of the oropharynx as well as false cords. Using a Miller 4 blade a grade 2 view was obtained and the AIROD^TM was advanced 1 cm past the vocal cords followed by the endotracheal tube while an assistant held the distal end. There was no significant desaturation or trauma to the vocal cords or oropharynx. Pre-loading the AIROD^TM with the endotracheal tube improved the speed and autonomy of the intubation.

Discussion

AIROD^TM is a single-use telescopic endotracheal intubation bougie. It is rigid, made of stainless steel and sterilized. It telescopes to two feet and has a specialized 20-degree angled tip. Once expanded it locks so it cannot be retracted. An endotracheal tube 7.0 or greater can be advanced over the telescoping bougie for smooth placement in the adult trachea.

AIROD^TM is non-malleable and can gently displace oropharyngeal tissue, it does not sag and pull like plastic bougies, the unique locking mechanism prevents collapse and the square handle improves dexterity as well as spatial awareness of the proximal tip.

AIROD^TM telescopes open allowing for storage in small spaces such as a pocket or a crash cart without damaging its integrity like so many bougies that are ruined when bent for storage. Because of its small size, it can be stored in a myriad of places and easily accessed by emergency personnel in the field, emergency department, intensive care unit and operating room.

AIROD^TM can be used with multiple different varieties of laryngoscopes. My preference is a Miller 4 laryngoscope because of the ability to lift the epiglottis and visualize the vocal cords especially in patients with a large tongue, limited mouth opening and decreased neck mobility. The AIROD^TM can be slid along the length of the laryngoscope blade if needed to overcome the force of oropharyngeal tissue. Once the AIROD^TM is advanced a few centimeters past the vocal cords the rigidity of the AIROD^TM allows advancement of the endotracheal tube with ease because it can withstand the forces applied by the oropharyngeal tissue without significant bending. I have also used a Macintosh laryngoscope with the AIROD^TM which allows for displacement of the tongue and oropharyngeal tissue but placement into the vallecula above the epiglottis can limit exposure to the vocal cords. The AIROD^TM can overcome the limitation of the Macintosh laryngoscope by directly lifting the epiglottis, exposing the vocal cords then the AIROD^TM can be gently slid along the posterior surface of the epiglottis past the vocal cords followed by advancement of an endotracheal tube for successful intubation. Because the AIROD^TM is made of steel, similar to the Gliderite stylet used with the Glidescope as well as laryngoscopes and rigid bronchoscopes, it is possible that if used incorrectly trauma to the oropharynx as well as the trachea may occur, and caution is advised.

The cost of the AIRODTM is similar to the Glidescope’s disposable covers that are used with each intubation. Because of the loss of direct sight and acute angles involved in the process of advancing an introducer during intubation with the Glidescope I do not recommend using the AIRODTM with the Glidescope. The AIRODTM was designed only to be used with adults.

Conclusion

AIROD^TM is a sterile single-use telescopic bougie that is used along with a laryngoscope when performing endotracheal intubation. Because of its small size it is easily stored in a pocket, helicopter, ambulance, crash cart, operating room, emergency department, intubation box and in the intensive care unit. Its rigidity helps displace oropharyngeal tissue improving the view of the vocal cords and it facilitates advancement of an endotracheal tube. It can also be used in the closed position as a stylet making it an ideal instrument for first-attempt intubation along with a laryngoscope.

Conflict of Interest Disclosures

The author Evan Denis Schmitz, MD is the inventor of the AIROD^TM.

References

1. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM; NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015 Apr;65(4):363-70. [CrossRef] [PubMed]
2. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013 Jan;20(1):71-8. [CrossRef] [PubMed]
3. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA. 2018 Jun 5;319(21):2179-89. [CrossRef] [PubMed]

Cite as: Schmitz ED. Single-use telescopic bougie: case series. Southwest J Pulm Crit Care. 2020;20(2):64-8. doi: https://doi.org/10.13175/swjpcc005-20 PDF 

Editor's Note: On April 19, 2020 Dr. Schmitz has submitted a video showing a 6 second intubation using the AIROD and a mannequin which is below.

Safety and Efficacy of Lung Recruitment Maneuvers in Pediatric Post-Operative Cardiac Patients

Renee L. Devor MD^1,2

Harjot K. Bassi MD³

Paul Kang MPH⁴

Tiffany Morandi MD²

Kristi Richardson RT⁵

John J. Nigro MD^2,6

Christine Tenaglia RT⁵

Chasity Wellnitz RN, BSN, MPH⁶

Brigham C. Willis MD^1,2,7

¹Division of Cardiac Critical Care, Phoenix Children’s Hospital, Phoenix, Arizona

²Department of Child Health, University of Arizona College of Medicine, Phoenix, Arizona

³Division of Critical Care, Phoenix Children’s Hospital, Phoenix, Arizona

⁴Department of Epidemiology and Biostatistics, University of Arizona College of Medicine, Phoenix, Arizona

⁵Department of Respiratory Therapy, Phoenix Children’s Hospital, Phoenix, Arizona

⁶Division of Cardiology, Phoenix Children’s Hospital, Phoenix, Arizona

⁷Department of Pediatrics, Creighton University School of Medicine, Phoenix, Arizona

Abstract

Background: Recruitment maneuvers are a dynamic process of transient increases in transpulmonary pressure intended to open unstable airless alveoli. Due to concerns regarding the hemodynamic consequences of recruitment maneuvers in children with heart disease, these maneuvers have not been widely utilized in this population. The objective of this study was to demonstrate the safety and efficacy of lung recruitment maneuvers in post-operative pediatric cardiac patients. We hypothesized that multiple recruitment maneuvers are physiologically beneficial and hemodynamically tolerated in children with congenital cardiac disease. 

Methods: Retrospective chart review was conducted of post-operative cardiac surgical subjects who received recruitment maneuvers, as well as a matched control group who did not, at a Cardiac ICU in a quaternary care free-standing children’s hospital. Repetitive lung recruitment maneuvers using incremental positive end-expiratory pressure were performed. Hemodynamic and respiratory physiologic variables were recorded.

Results: Sixty-one post-operative cardiac subjects had a total of 435 lung recruitment maneuvers. Assessment of hemodynamic tolerability demonstrated no change in MAP, HR, or CVP during or after the maneuvers. There was a 28% increase in dynamic compliance following recruitment maneuvers (p <0.01, 95% CI). Specific outcomes in the 59 matched control subjects demonstrated no significant difference in length of mechanical ventilation (p = 0.26), length of hospital stay (p = 0.28), mortality (p = 0.58) or difference in occurrence of pneumothorax (p = 0.26). 

Conclusions: Post-operative pediatric cardiac surgical subjects tolerated repeated lung recruitment maneuvers without significant hemodynamic changes. The maneuvers successfully improved dynamic compliance without any adverse effects.

Introduction

Mechanical ventilation is a common therapy used for pediatric patients in the intensive care unit and is frequently used for children with congenital cardiac disease following surgical repair. However, it is well known that mechanical ventilation can induce lung injury or worsen preexisting lung disease (1-3). In patients with congenital cardiac disease, it is crucial to protect the lung from injury and optimize ventilation and oxygenation due to their underlying hemodynamic and physiologic fragility (4, 5). Post-operatively, several factors including general anesthesia, cardiopulmonary bypass, atelectasis, and hypoxemia can contribute to lung dysfunction, which may lead to prolonged mechanical ventilation (6). Children with such prolonged ventilation are at a higher risk for poor overall outcome due to a variety of ventilator-associated morbidities (7, 8). Therefore, it is of practical value to protect the lungs and reduce the length of time mechanical ventilation is required.

Alveolar injury can be caused by the repetitive opening and closing of alveoli when inadequate positive end-expiratory pressure (PEEP) is provided and this can generate shear stress within the alveoli and promote injury (9-10). Lung recruitment maneuvers have been defined as transient increases in the transpulmonary pressure used to open recruitable collapsed alveoli and increase end expiratory lung volume (11-13). Recruitment maneuvers are often considered useful in patients, especially those with acute respiratory distress syndrome (ARDS), to potentially decrease ventilator-induced lung injury by improving oxygenation and lung compliance while reducing the risk of atelectrauma by re-opening and stabilizing collapsed alveoli (11,13-18).

Increased intrathoracic pressure can affect right and left ventricular preload due to decreased venous return, changed right ventricular afterload, and altered biventricular compliance (4,10,14,19-21). This may lead to decreased stroke volume leading to short periods of hypotension, bradycardia, and impaired cardiac output, which is of significant concern in patients with congenital cardiac disease (14). Many patients with congenital cardiac disease must undergo surgical procedures which lead to lung collapse after induction of general anesthesia and during mechanical ventilation (15,22). In those patients undergoing cardiac surgery with cardiopulmonary bypass, significant atelectasis occurs which impairs right ventricular (RV) function. However, lung recruitments using positive pressure have been shown to re-expand collapsed alveoli and improve RV function (23-26). There is a theoretical risk of developing barotrauma leading to pneumomediastinum or pneumothorax during a recruitment; however this is likely less a risk in cardiac surgical patients with relatively healthy lungs (10,27,28).

These cardiopulmonary interactions and hemodynamic concerns limit the willingness of many clinicians to perform positive-pressure recruitment maneuvers in patients with underlying cardiac pathology, making studies involving this population uncommon. One study (29) evaluated the use of a recruitment maneuver performed in twenty pediatric patients with congenital cardiac disease who underwent surgical repair. A single recruitment maneuver was performed shortly after coming off of cardiopulmonary bypass and repeated once in the intensive care unit. Although this study was able to demonstrate an improvement in oxygenation, dynamic lung compliance, arterial to end-tidal CO₂ gradient, and end expiratory lung volume, it excluded patients with residual intracardiac lesions following surgery, patients with valvular regurgitation, or respiratory failure defined as FiO2 >0.8. Due to the relatively small number of patients included in this study, as well as their protocol prescribing only two recruitment maneuvers performed per patient, it is difficult to ascertain the overall long-term safety and potential benefits that repeated lung recruitments may provide.

In this study, we aimed to investigate the safety and efficacy of increment-decrement recruitment maneuvers in a larger pediatric patient population following surgery for congenital cardiac disease, hypothesizing that multiple recruitment maneuvers are physiologically beneficial and hemodynamically tolerated in these patients. The safety of these maneuvers was evaluated by examining changes in mean arterial pressure (MAP), heart rate (HR), and central venous pressure (CVP) before, during, and after the recruitment maneuvers. The efficacy of the recruitment maneuvers was determined by changes in oxygenation index (OI) and dynamic lung compliance (Cdyn) following recruitment. To further evaluate the safety of repetitive recruitment we reviewed specific clinical outcomes that included length of mechanical ventilation, length of hospital stay (LOS), mortality and occurrence of pneumothorax and compared to a control group.

Materials and Methods

This study was reviewed and approved by the Institutional Review Board at Phoenix Children’s Hospital. Subjects who received lung recruitment maneuvers post-operatively, as identified in the electronic medical record, in the Phoenix Children’s Hospital cardiac intensive care unit, a quaternary referral center, from July 2011 through June 2012 following implementation of a lung recruitment protocol, were included in the study. Further inclusion criteria included subjects from 0-18 years of age who were admitted immediately after having open heart surgery with both single- and two-ventricle physiology and who remained on invasive mechanical ventilation. All subjects were mechanically ventilated with Servo-I ventilators (Maquet Critical Care, Solna, Sweden). Subjects with a tracheostomy or who were receiving extracorporeal membrane oxygenation (ECMO) support were excluded from the analysis. A comparison group of consecutive control subjects who did not receive recruitment maneuvers was selected in the following year from July 2012 to June 2013 following an institutional hiatus of the maneuvers during which time quality data was reviewed and the safety of the protocol was assessed. Recruitment maneuvers have subsequently been reinstated and are now standard care in our post-operative cardiac patients on invasive mechanical ventilation.

During the study period, lung recruitment maneuvers were a new standard of care implemented at our institution in the cardiac intensive care unit. They were performed by either the respiratory therapist or attending physician. Most patients had twice daily recruitment maneuvers unless more were clinically indicated based on chest x-ray findings or lung mechanics. The patients may also have fewer recruitment maneuvers if they were hemodynamically unstable, having other procedures, if there was ongoing resuscitation or at the discretion of the attending physician.

The recruitment maneuver was performed in pressure control mode regardless of the subject’s baseline mode of ventilation. Initial settings were adjusted to achieve a tidal volume of 6mL/kg. PEEP was increased from baseline by 1-2 cmH₂O increments while maintaining a fixed inspiratory driving pressure (PIP-PEEP) with each increase sustained for one-minute intervals until either the tidal volume (V_T) or dynamic compliance (Cdyn) declined (Figure 1).

Figure 1. Lung recruitment maneuver: recruitment maneuver protocol courtesy of Boriosi et al. (11). Each horizontal bar represents an incremental increase of PEEP by 2 cm H₂O in one-minute increments from baseline PEEP.

The recruitment maneuver was terminated if the mean airway pressure surpassed 28 cm H₂O. V_T and Cdyn were documented with each increase in PEEP. Once the critical opening pressure was identified, PEEP was decreased in a step-wise manner in one-minute 1-2 cmH₂O decrements to the critical closing pressure identified by a decrease in V_T or Cdyn. Following this point, the PEEP was again increased to the identified critical opening pressure for one minute. It was then brought back down to 2 cmH₂O above the critical closing pressure (i.e. “optimal PEEP” level demonstrated by improved compliance and increased tidal volume with less ventilating pressure). The subject was then placed back on their original mode of ventilatory support with the PEEP adjusted to the optimal level, as determined during the recruitment maneuver in order to maintain the newly recruited areas of the lungs open.

Data Collected: A database was generated with 61 subjects who had lung recruitment maneuvers, and a convenience sample of 59 matched control subjects were selected from our Society for Thoracic Surgeons (STS) database. Demographic data was collected including age, body surface area, associated anomalies or chromosomal abnormalities, cardiac diagnosis, and type of surgical procedure. Clinical outcomes data collected included length of mechanical ventilation, length of hospital stay, mortality, and occurrence of pneumothorax.

Hemodynamic variables including MAP, HR, and CVP were monitored and recorded by the bedside nurse and/or respiratory therapist. For each variable, the two hourly vital sign measurements prior to the start of the maneuver, two measurements during, and the first two hourly measurements following the maneuver were included for analysis. In an attempt to minimize error and to provide a more accurate representation of the subject’s status at the time of interest, the two vital sign measurements in each category were averaged as physiologic variables are dynamic. The respiratory physiologic variables monitored were dynamic compliance and oxygenation index. In order to further investigate the clinical effects of potentially decreased cardiac output, we reviewed the changes in inotropic and vasopressor support before, during, and after the performance of each recruitment maneuver.

Statistical Analysis: Subject demographic and clinical characteristics between the control and recruitment maneuver groups were reported as medians, interquartile ranges (IQR) for continuous variables and frequencies, percentages for categorical variables. The Wilcoxon Rank Sum was used to compare the continuous variables; while Chi-squared/Fisher’s Exact Tests were used to compare the categorical variables.  The Linear Mixed Model was used to ascertain trends in hemodynamic outcomes (mean arterial pressure, heart rate, and central venous pressure) across three timepoints (before, during and after the recruitment maneuver).  If the overall trend showed statistical significance, the Wilcoxon Signed Rank Test was used to ascertain differences via multiple comparisons followed by the Bonferroni adjustment for multiple comparisons.  Before and after differences in physiological outcomes (oxygenation index and dynamic compliance) were assessed using the Wilcoxon Signed Rank.  All p-values were 2-sided and p<0.05 was considered statistically significant. All data analyses were conducted using STATA version 14 (STATACorp; College Station, TX).  

Results

A total of 61 subjects underwent lung recruitment from June 2011 to June 2012 (Table 1) accounting for a total of 439 recruitment maneuvers during this time.

Table 1. Comparison of subjects receiving recruitment maneuvers versus controls.

Recruitment was initiated in the post-operative period once deemed safe by the primary intensivist. The maneuvers were performed as frequently as every two hours but, on average, subjects in the cohort received 2 recruitment maneuvers per ventilator day. Both groups had similar congenital heart disease diagnoses with an average Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery Mortality Score of 3 in each group covering a variety of anatomical defects and surgical procedures performed. Subjects with residual intracardiac lesions on intraoperative transesophageal echocardiogram were included in the study.

Hemodynamics: All 61 subjects tolerated the maneuvers with no hemodynamic instability defined as hypotension, need for fluid bolus during the recruitment, bradycardia, or dysrhythmias. No subject had any of the maneuvers discontinued prematurely. We found no significant difference in the MAP (p = 0.13, 95% CI) (Figure 2a) or HR (p = 0.74, 95% CI) (Figure 2b) during the time intervals measured.

Figure 2. Hemodynamics: comparison of hemodynamic measurements before, during, and after the recruitment maneuvers. There was no significant change in MAP (Fig 2a), HR (2b), or CVP (2c) during or after the maneuvers. Boxplot with whiskers with minimum/maximum 1.5 IQR.

Due to the transient increase in intrathoracic pressure that theoretically results in a decrease in venous return and therefore cardiac output, CVP was monitored throughout the recruitments. The CVP measurement did not show a significant change with the recruitment maneuver (p = 0.79, 95% CI) (Figure 2c).

In order to further investigate the clinical effects of potentially decreased cardiac output, we reviewed the changes in inotropic and vasopressor support surrounding the performance of the recruitment maneuvers. All infusion rates of epinephrine, norepinephrine, vasopressin, dopamine, milrinone, and calcium were documented prior to, during, and after lung recruitments. Of the 439 recruitment maneuvers performed, 84% were performed without any change in inotropic support during or within 1 hour after completion of the maneuver. Inotropic support was decreased after the recruitment in 12% of maneuvers. Only 3% of maneuvers required an increase in support. No subjects had any significant hypotension requiring fluid bolus administration during or immediately after the maneuvers.

Efficacy: The efficacy of recruitment maneuvers on lung function was determined by measuring changes in the OI and Cdyn before and after recruitment. There was no statistically or clinically significant change in the OI with a median OI before recruitment of 7.3 (IQR 4.1-12.6) and after 7.7 (IQR 4.6-12.6) (p = 0.96, 95% CI) (Figure 3a).

Figure 3. Efficacy: comparison of physiologic measures used to assess efficacy of the recruitment maneuvers. No significant change was demonstrated in the OI before and after recruitment (3a). There was a significant increase in Cdyn by an average of 28% immediately after the maneuvers (3b). Boxplot with whiskers with minimum/maximum 1.5 IQR.

Of the 439 maneuvers, 83% resulted in a measurable improvement of the Cdyn with all 61 of the subjects demonstrating an increase at least once over the course of the interventions. The Cdyn increased from 0.45 ml/cmH₂O/kg (IQR 0.37-0.57) to 0.58 ml/cmH₂O/kg (IQR 0.47-0.75) afterwards (p < 0.001, 95% CI). (Figure 3b). The duration of improved Cdyn was an average of 8 hours +/- 11.4 hours. Subjects continued to show improvement with repeated efforts.

Clinical Outcomes. All subjects included in this study were on invasive mechanical ventilation support on return from cardiac surgery for a minimum of 24 hours. As shown in Table 2, there was no significant difference in the number of ventilator days between the recruitment maneuver and control groups (p = 0.26, 95% CI).

Table 2. Clinical outcomes.

There was also no difference in the occurrence of extubation failure requiring reintubation between both groups (p = 0.52). There was no difference in hospital LOS with the RM group staying 17.5 days (10.5 – 27) and control group 15 days (9.5 – 23) (p = 0.28, 95% CI) or in the rate of in-hospital mortality (p = 0.58, 95% CI). Despite the theoretical concern for development of pneumothorax with recruitment maneuvers, there was no significant difference in the occurrence between the two groups (p = 0.26, 95% CI).

Discussion

Our results suggest that lung recruitment maneuvers are well tolerated in the pediatric post-operative cardiac patient population both with and without residual intracardiac shunts, and may be repeated for the duration of their time requiring invasive mechanical ventilation. Despite being at high risk of hemodynamic instability shortly after surgery, especially following complex repair and prolonged cardiopulmonary bypass time, our subjects did not require significant preload optimization or escalation of inotropic support during the maneuvers. We were also able to demonstrate that there was an improvement in dynamic lung compliance following the maneuver. Not only were these maneuvers tolerated from a hemodynamic standpoint, but there were no adverse outcomes when compared to control subjects with no difference in the length of mechanical ventilation, LOS, mortality, or the occurrence of pneumothorax.

Advocacy for the optimization of oxygenation and ventilation through the use of an “open lung” strategy, especially in the treatment of ARDS, has been present in the critical care literature for decades. Multiple reports have described the importance of lung recruitment with high inspiratory pressures in addition to the appropriate PEEP above closing pressures to maintain optimal gas exchange and minimize hypercapnia (30). Recruitment maneuvers are recommended in the protective ventilation strategy in adult post-operative patients who have undergone cardiac surgery with significant benefits as compared to traditional ventilation (31,32). To our knowledge, there is very limited data on the use of lung recruitment maneuvers in the pediatric cardiac patient population with the majority of the pediatric literature focusing on the use of these maneuvers in patients with ARDS. Scohy et al. (29) previously evaluated the use of recruitment maneuvers in subjects undergoing surgery for congenital cardiac disease but excluded several key subgroups of these subjects and did not evaluate the continued use of recruitment maneuvers over the entire course of mechanical ventilation. Amorim et al. (6) assessed the tolerance of recruitment maneuvers in a small population of infants who were prone to pulmonary arterial hypertension and excessive pulmonary circulation just after skin closure for open heart surgery. In general, data on the safety of these maneuvers in pediatric patients is very limited.

The efficacy of lung recruitment maneuvers in patients with ARDS remains controversial with some studies suggesting an improvement in oxygenation and dynamic or static compliance (1,11,20,21,33-35), some demonstrating brief or no improvement (36,37), and others that show improvement but suggest that the deleterious hemodynamic effects may outweigh the benefits (14). In children with ARDS, a staircase recruitment strategy has been described to improve oxygenation with increasing PaO_2. In order to sustain improved oxygenation, the PEEP must be set above the critical closing pressure of the lung following recruitment (11,21,38,39). Boriosi et al. (11) further described that a “re-recruitment” maneuver that was performed at critical opening pressures for a short period of time improved the PaO₂/FiO₂ ratio for up to 12 hours and OI for up to four hours following the recruitment maneuver. In our study, we were not able to demonstrate an improvement in the OI. However, we did demonstrate a significant improvement in Cdyn of 29% following completion of each recruitment which was sustained for eight hours. The lack of improvement in oxygenation may be secondary to less primary lung injury in our patient population, or due to the common presence of residual intracardiac shunts. The increase in Cdyn may be a clinically significant change for some patients and could help reduce the time on invasive mechanical ventilation.

The overall goal of recruitment maneuvers is to open atelectatic alveoli, increase end expiratory lung volume, and improve gas exchange. However, as discussed, generation of high intrathoracic pressures during the maneuvers can theoretically result in hemodynamic instability (4,10,14,20,21). Currently, there is no specific non-invasive monitoring that is the best indicator for hemodynamic assessment during recruitment maneuvers, with vital sign changes serving as a surrogate marker for the safety of the recruitment maneuver (40). In our study, there was no change in MAP, HR, or CVP from baseline, during, or after the maneuvers indicating that they were well tolerated from a hemodynamic standpoint with 97% of the recruitment maneuvers using the same or less inotropic support and no subject required fluid bolus administration for hypotension during any of the maneuvers.

The occurrence of barotrauma, including pneumomediastinum and pneumothorax, has been reported with the intermittent increase in peak airway inspiratory pressures (10,27,28). In our study, there was no significant difference in the occurrence of pneumothorax between the two groups. With the preponderance of studies on recruitment maneuvers being performed in the adult ARDS patient population, there is limited data on pediatric outcomes in mortality and duration of mechanical ventilation. A Cochrane review performed by Hodgson et al. (41) demonstrated no reduction in mortality or length of mechanical ventilation following recruitment maneuvers in adult ARDS patients. In our study, we demonstrated similar findings in that there was no difference in mortality, length of mechanical ventilation, or LOS in pediatric post-operative congenital cardiac patients with or without the maneuvers.

There were several limitations to our study. This was a single-center, retrospective study that involved a small pediatric cardiac population. Our assessment of cardiac output was dependent on measurements of MAP and CVP. We also did not investigate the occurrence of hypercapnia during the recruitment maneuvers. Overdistension of open alveoli can occur resulting in an increase in pulmonary vascular resistance and a decrease in blood flow to the alveoli, thereby increasing dead space ventilation (21). There are a number of studies demonstrating that throughout recruitment maneuvers there is an increase in PaCO₂, with a potential need to titrate the respiratory rate on the ventilator in order to maintain constant minute ventilation throughout the maneuver, as this development of hypercapnia during the maneuvers may result in adverse effects (11,34,36,41). A multifaceted approach to monitoring the effectiveness as well as any negative consequences of these maneuvers including end-expiratory lung volumes, dead space ventilation, pulmonary compliance, volumetric capnography as well as bedside ultrasound would be beneficial (40). This study was conducted prior to our institution utilizing volumetric CO₂ analysis to monitor physiologic gas exchange as well as dead-space ventilation during mechanical ventilation.

Conclusion

Overall, our study demonstrated that pediatric post-operative cardiac subjects, having a wide variety of cardiopulmonary physiology, tolerated repeated recruitment maneuvers without significant hemodynamic changes or adverse outcomes. As has been the case in many previous studies, we did not find any significant improvement in oxygenation, length of mechanical ventilation, or length of stay. However, as recruitment maneuvers have been shown to be an integral part of lung protection strategies and to benefit adults following open heart surgery, it is possible that our pediatric post-operative cardiac patients could benefit from the integration of recruitment maneuvers into ventilator management strategies while on invasive mechanical ventilation. Future prospective studies need to be conducted to further evaluate the potential benefit and utility of lung recruitment maneuvers in pediatric patients without significant lung disease.

Acknowledgements

We would like to thank the staff of the Pediatric Cardiovascular Intensive Care Unit at Phoenix Children’s Hospital for their assistance and support in this study. We would also like to acknowledge the work of Juan P Boriosi, MD and his colleagues for use of their recruitment protocol and RM diagram (Figure 1) in our study.

Contributions: Renee L. Devor MD^1,4,5,6, Harjot K. Bassi, MD^1-6, Paul Kang MPH⁴, Tiffany Morandi MD^1-3, Kristi Richardson RT^2,3, John J. Nigro MD², Christine Tenaglia RT^2,3, Chasity Wellnitz RN, BSN, MPH^2,4, and Brigham C. Willis MD^3,6

¹Literature search, ²Data collection, ³Study Design, ⁴Analysis of data, ⁵Manuscript preparation, ⁶Review of manuscript

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Cite as: Devor RL, Bassi HK, Kang P, Morandi T, Richardson K, Nigro JJ, Tenaglia C, Wellnitz C, Willis BC. Safety and efficacy of lung recruitment maneuvers in pediatric post-operative cardiac patients. Southwest J Pulm Crit Care. 2020;20(1):16-28. doi: https://doi.org/10.13175/swjpcc068-19 PDF 

January 2020 Critical Care Case of the Month: A Code Post Lung Needle Biopsy

Sarika Savajiyani MD and Clement U. Singarajah MBBS

 Phoenix VA Medical Center

Phoenix, AZ USA

A 67-year-old man with a history of stage IIA rectal adenocarcinoma post neoadjuvant chemoradiation presented with a near code event after elective CT guided biopsy of an enlarging left lower lobe lung nodule. The patient became bradycardic and profoundly hypotensive immediately after the CT guided biopsy with the following vital signs: Systolic BP < 90 mmHg, HR 40/min sinus bradycardia, SpO₂ on 100% oxygen non rebreather was 90%. Telemetry and EKG showed ST elevation in the anterior leads. He complained of vague arm and leg weakness and tingling, but did not lose consciousness or suffer a cardiac arrest. 

A CT scan was performed about 2-3 minutes after the patient deteriorated (Figure 1).

Figure 1. A-E: Representative images from CT scan in soft tissue windows. Lower: Video of CT scan in soft tissue windows.

What radiographic finding likely explains the patient’s clinical deterioration?  (Click on the correct answer to be directed to the second of six pages)

1. Arterial air embolism
2. Pneumothorax
3. Pulmonary edema
4. Pulmonary Embolism
5. Venous air embolism

Cite as: Savajiyani S, Singarajah CU. January 2020 critical care case of the month: a code post lung needle biopsy. Southwest J Pulm Crit Care. 2020;20(1):1-6. doi: https://doi.org/10.13175/swjpcc042-19 PDF