AB168. SOH23ABS_235. Level two strategies in the management of a severe case of type 2 respiratory failure

Background: We describe a 42-year-old previously healthy caucasian man who presented with respiratory failure due to bilateral pneumonia and underlying mitral valve prolapse managed with level 2 ventilation strategies in a regional intensive care unit (ICU) centre.

Methods: Admission computed tomography exhibited bilateral infiltrates, larger on the right with an effusion. Initial pressure controlled-bilevel positive airway pressure (BiPAP) ventilation, paralysis, a Fraction of inspired oxygen of 1.0 and broad-spectrum antimicrobial cover only maintained a low arterial partial pressure of oxygen (PaO₂, 7–8 kPa). Therefore, an ultrasound-guided right chest drain was inserted. Level 2 ventilation strategies were initiated with Airway Pressure Release Ventilation - Time Controlled Adaptive Ventilation (APRV-TCAV) and nitric oxide. We referred the patient for extra-corporeal membrane oxygenation (ECMO) but with time the PaO₂ improved. We initiated proning to maximize alveolar recruitment and improve ventilation-perfusion mismatch. Prior to proning, a Grade 3 systolic murmur was auscultated. A point-of-care-ultrasound (POCUS) was performed once supine and much turbulence was noted over the mitral valve. A departmental transthoracic echocardiogram (TTE) followed by trans-oesophageal echocardiogram (TOE) confirmed severe mitral valve prolapse and ruptured chordae tendinae. An intra-aortic balloon pump (IABP) was inserted by our Cardiology colleagues as a temporizing measure.

Results: The Cardiothoracic Service of the ECMO centre accepted the patient for definitive surgical replacement of the mitral valve once sepsis had abated.

Conclusions: In conclusion, APRV-TCAV can help improve oxygenation in those with severe acute respiratory distress syndrome (ARDS) and underlying valvular pathology in a non-cardiac surgery, non-ECMO centre. TOE was required to delineate the severity of the underlying pathology. Further temporizing strategies including proning and placement of an IABP.

Keywords: Respiratory failure; Airway Pressure Release Ventilation - Time Controlled Adaptive Ventilation (APRV-TCAV); mitral valve prolapse; level 2 ventilation strategies; intra-aortic balloon pump (IABP)