Lung sonography in the choise of best mask for niv
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In questo caso clinico di un paziente Sla che doveva iniziare la ventilazione meccanica non invasiva abbiamo confrontato l'utilizzo di tre maschere valutando e confrontando oltre la sensazione soggettiva, i volumi del ventilatore e le perdite registrate con la presenza e il numero di artefatti ecografici del torace.
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Lung sonography in the choise of best mask for niv
- 1. Lung sonography in the choise of the best mask for NIV in ALS patient A. Longoni*/** , P. Pozzi **, A. Paddeu** * S.R.R.F. - ** Cardio-Respiratory Rehabilitation Center Paola Giancola Foundation, S. Anthony Abate Hospital Cant湛, ASST Lariana, Italy angelo.longoni@asst-lariana.it ! !!E.R. a 77 year-old woman suffering from ALS with tetraparesis at lower limbs was hospitalized to start non invasive mechanical ventilation (NIMV). The basal pulmonary function testings (PFT) were compatible with a severe reduction of the forced vital capacity (FVC) as well as of the maximum inspiratory and expiratory pressures (Mip=32, Mep=28, FVC=69%,Fev1=83%, Fev1/FVC=131%, Pef=67%), PCEF= 380 lt/m. !! Case history The Niv treatment Conclusion: At the discharge (31/07 to 21/08/2018) the patient was able to carry the NIMV all night long and she had a satisfactory diaphragmatic excursion with 1,1 cm to 3 cm in normal and 3,8 cm to 5,2 cm in forced breathing. Mip=33, Mep=25, PCEF= 360 lt/m, FVC=76%,Fev1=88%, Fev1/FVC=127%, Pef=66%). During NIMV she had 1,2 cm, 4,6 cm, 3 cm in ventilation with oronasal, nasal and facial mask ( Fig. 8-9-10) respect to normal ventilation (Fig.6) and recruitment of 3,5,9 A lines (Fig. 13-14-15). Diaphragmatic Sonography can be an excellent verification tool, safe, fast, not expensive method to be performed, at the patient's bed, to choose the most suitable mask for the needs and patients face during non invasive ventilation. The patient has performed NIMV (Amstral 150) with a integrated hot humidifier and different masks (Fig.2-7-12). The parameters were: S/T mode, Avaps on, VT= 400 ml, Ipap max= 20, Ipap min=16, Epap=6, FR=10, Ti =1.2. The Ultrasound (US) were performed at the admission and at the discharge with patient in 45属 lying down position (Fig.1) with normal and forced breathing (Fig.6-11), in M-mode with a convex probe 1-5 MgHz. We have studied the diaphragmatic excursion in anterior subcostal view and the presence of A line in upper right thoracic position. We have studied the ventilator index, mask leaks and the problems and sensations reported by the patient during NIMV with the different masks compared with US parameters: 1) The oronasal mask was the first choice but gave it problems of eyes for heigh leaks due to the thin shape of the cheeks. The ventilator had high leaks and lower tidal volume values ( Fig.5) , lower US diaphragmatic excursion (Fig. 3) and lower presence of A lines ( Fig.4) . 2) The nasal mask was most comfortable for the cheeks and nose and had less ventilator leaks (Fig.10). It had created problems related to the opening of the mouth during sleep even if it had the maximum value of diaphragmatic excursion (Fig.8), but low tidal volume ( Fig.10) and a good presence of A lines ( Fig. 9). 3) The total face mask was the most comfortable. A smaller diaphragmatic excursion ( Fig.13) than the second mask but an higher tidal volume ( Fig.15), an alveolar recruitment linked to the high number of lines A (Fig.14), a reduced mask leaks ( Fig. 15) and elimination of the psychological problems due to opening mouth. Investigations Fig.1 Fig.2 Fig.3 Fig.4 Fig.5 Fig.6 Fig.7 Fig.8 Fig.9 Fig.10 Fig.11 Fig.12 Fig.13 Fig.15Fig.14 Masks! Oronasale! Nasale! Facciale! +!confort! 0! 1! 2! 0!problems! 0! 1! 2! 0!Skin!lesions! 0! 1! 2! 0!Mask!!!leak!(L/min)! 0! 1! 2! +!Vte!!ml! 0! 1! 2! +!Diaphragmatic! excursion!(cm)! 0! 2! 1! +!Alveolar! recruitment!(A0lines)! 0! 1! 2! Total! 0! 8! 13! 25!Gennaio!2020!