05 July 2016 : Case report
Worsening Hypoxemia in the Face of Increasing PEEP: A Case of Large Pulmonary Embolism in the Setting of Intracardiac Shunt
Unusual or unexpected effect of treatment, Rare coexistence of disease or pathologyGlen T. GranatiDEF, Getu TeressaBDEF
Am J Case Rep 2016; 17:454-458
BACKGROUND: Patent foramen ovale (PFO) are common, normally resulting in a lefttoright shunt or no net shunting. Pulmonary embolism (PE) can cause sustained increased pulmonary vascular resistance (PVR) and right atrial pressure. Increasing positive end-expiratory pressure (PEEP) improves oxygenation at the expense of increasing intrathoracic pressures (ITP). Airway pressure release ventilation (APRV) decreases shunt fraction, improves ventilation/perfusion (V/Q) matching, increases cardiac output, and decreases right atrial pressure by facilitating low airway pressure.
CASE REPORT: A 40-year-old man presented with dyspnea and hemoptysis. Oxygen saturation (SaO2) 80% on room air with Aa gradient of 633 mmHg. Post-intubation SaO2 dropped to 71% on assist control, FiO2 100%, and PEEP of 5 cmH20. Successive PEEP dropped SaO2 to 60–70% and blood pressure plummeted. APRV was initaiated with improvement in SaO2 to 95% and improvement in blood pressure. Hemiparesis developed and CT head showed infarction. CT pulmonary angiogram found a large pulmonary embolism. Transthoracic echocardiogram detected right-to left intracardiac shunt, with large PFO.
CONCLUSIONS: There should be suspicion for a PFO when severe hypoxemia paradoxically worsens in response to increasing airway pressures. Concomitant venous and arterial thromboemboli should prompt evaluation for intracardiac shunt. Patients with PFO and hypoxemia should be evaluated for causes of sustained right-toleft pressure gradient, such as PE. Management should aim to decrease PVR and optimize V/Q matching by treating the inciting incident (e.g., thrombolytics in PE) and by minimizing ITP. APRV can minimize PVR and maximize V/Q ratios and should be considered in treating patients similar to the one whose case is presented here.
Keywords: Disease Progression, computed tomography angiography, Cardiac Surgical Procedures, Echocardiography, Transesophageal, Foramen Ovale, Patent - surgery, Hypoxia - etiology, Oxygen - blood, Positive-Pressure Respiration - adverse effects, Pulmonary Embolism - diagnosis
22 September 2022 : Case reportRare Case of Persistently Depressed T Lymphocyte Subsets After SARS-CoV-2 Infection
Am J Case Rep In Press; DOI: 10.12659/AJCR.937760
22 September 2022 : Case reportCentral Retinal Vein Occlusion After Discontinuation of Rivaroxaban Therapy in a Young Patient with COVID-1...
Am J Case Rep In Press; DOI: 10.12659/AJCR.937739
19 September 2022 : Case reportInhaled Nitric Oxide in Acute Severe Pulmonary Hypertension and Severe Acute Respiratory Distress Syndrome ...
Am J Case Rep In Press; DOI: 10.12659/AJCR.937147
27 Sep 2022 : Case reportCompound Heterozygote Mutation in the SMPD1 Gene Leading to Nieman-Pick Disease Type A
Am J Case Rep In Press; DOI: 10.12659/AJCR.937220
26 Sep 2022 : Case reportAn Infant Presenting with Interstitial Lung Disease Diagnosed Later as Hunter Syndrome: A Case Report
Am J Case Rep In Press; DOI: 10.12659/AJCR.937527
26 Sep 2022 : Case reportAcute Intermittent Porphyria: Complete Phenotype in a Patient with p.Arg173Trp Variant in Thailand
Am J Case Rep In Press; DOI: 10.12659/AJCR.937695
Most Viewed Current Articles
13 Jul 2022 : Case reportWhistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound
Am J Case Rep 2022; 23:e936441
23 Feb 2022 : Case reportPenile Necrosis Associated with Local Intravenous Injection of Cocaine
Am J Case Rep 2022; 23:e935250
06 Dec 2021 : Case reportLipedema Can Be Treated Non-Surgically: A Report of 5 Cases
Am J Case Rep 2021; 22:e934406