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Case Reports
. 2024 Jan 23:48:101985.
doi: 10.1016/j.rmcr.2024.101985. eCollection 2024.

High PEEP extubation as guided by esophageal manometry

Kathryn M Pendleton  1 , Jacob Fiocchi  2 , Julia Meyer  3 , Alexandra Fuher  3 , Sarah Green  4 , William M LeTourneau  5 , Ronald A Reilkoff  1
Affiliations
Case Reports

High PEEP extubation as guided by esophageal manometry

Kathryn M Pendleton et al. Respir Med Case Rep. .

Abstract

The ventilatory management of morbidly obese patients presents an ongoing challenge in the Intensive Care Unit (ICU) as multiple physiologic changes in the respiratory system complicate weaning efforts and make extubation more difficult, often leading to increased time on the ventilator. We report the case of a young adult male who presented to our ICU on two separate occasions with hypoxemic respiratory failure requiring intubation. Esophageal manometry (EM) guided positive end expiratory pressure (PEEP) titration was utilized during both ICU admissions to improve oxygenation and aid in extubation with spontaneous breathing trials performed on higher-than-normal PEEP settings and successful liberation on both occasions.

Keywords: Esophageal manometry; Morbid obesity; Obese; Positive end expiratory pressure (PEEP); Spontaneous breathing trials (SBT); Ventilator weaning.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Pre EM Titration. Marked cardiac enlargement with increased pulmonary vascularity. Prominent diffuse bilateral pulmonary infiltrates. Remainder unremarkable.
Fig. 2
Fig. 2
Post EM Titration. Endotracheal tube tip is about 3.9 cm above the carina. NG tube overlies the mediastinum, the tip not seen, and can be confirmed by abdominal radiograph. Diffuse bilateral patchy airspace disease, similar to prior. No large effusions or pneumothorax. Unchanged cardiac size.
Fig. 3
Fig. 3
Pre EM Titration (admit 2). Portable view of the chest is performed. Endotracheal tube is in the right mainstem bronchus and should be repositioned approximately 2–3 cm in the more proximal airway. Pulmonary vascular congestion is present possibly due to hypoaeration of the lungs. Heart appears enlarged. Retrocardiac opacity likely due to left lower lobe atelectasis or possibly pneumonia.
Fig. 4
Fig. 4
Post EM Titration (admit 2).Marked left lower lobe atelectasis and/or infiltrate. Right lung grossly clear. Tubes and lines grossly unchanged.
See this image and copyright information in PMC

References

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