Proportional Pressure Support (PPS) Clinicians successfully match patient s respiratory demands and facilitate weaning by using PPS

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1 LOREM IPSUM D ÜBERSCHRIFT 3. Überschrift Lorem ipsum Proportional Pressure Support (PPS) Clinicians successfully match patient s respiratory demands and facilitate weaning by using PPS 1 Fußnote A Case Study dies ist eine lange Beschreibung über mehrer Zeilen die weiteren Punkte sind alle durch eine Linie getrennt der Zeilenabstand ist immer gleichbleibend 9,5 pt es gibt keine untersch. Zeilenabstände mehr Lorem ipsum O2 Ullamcorper suscipit lobortis 10 % Brian Stewart, BA, RRT, NPS Adult Critical Care Coordinator Carle Foundation Hospital

2 2 PROPORTIONAL PRESSURE SUPPORT (PPS) The patient is a 72-year old female transferred to our facility with acute respiratory failure, hypoxia, lactic acidosis, septic shock, and acute renal failure. Her history includes significant COPD, CVA, diabetes mellitus type 2, tardive dyskinesia, hyperlipidemia, hypothyroidism, and depression. After being sedated with Propofol and Fentanyl, she was started on Levophed and IV fluids. Her respiratory rate was 33 with obvious accessory muscle use. Her arterial blood gas showed a severe metabolic acidemia. INITIAL ARTERIAL BLOOD GAS RESULTS: ph 7.01 PaCO 2 15 PaO HCO BE INITIAL VENTILATOR SETTINGS Application Mode VC/AC with AutoFlow Tidal volume (Vt) 400 ml (8 ml/kg of ideal body weight) Respiratory Rate 14, PEEP 8 FiO2 1.0 Figure 1: Initial chest X-ray

3 3 Figure 2: Initial ventilator settings The initial mode of ventilation was VC/AC with AutoFlow. Given the erratic spontaneous breathing despite moderate sedation, this approach needed to be altered for the condition at hand. To help correct her acidemia, the patient was taking larger than set tidal volumes (Vt). The patient s respiratory drive needed to control the level of support provided by the ventilator. The mode of ventilation was changed to Proportional Pressure Support (PPS). The thought was to allow the patient to take control of ventilation. As the acidemia resolves, her respiratory drive should decrease, as would Vt and spontaneous rate.

4 4 PROPORTIONAL PRESSURE SUPPORT (PPS) Figure 3: Initial PPS settings The patient was able to take the Vt she desired. Her accessory muscle use diminished and she appeared much more comfortable. Initial PPS settings were 8 of flow assist and 8 of volume assist. Over a period of time, the flow assist control was adjusted to 4 and the volume assist was adjusted to Automatic Tube Compensation was also added to overcome the patient s resistance to the endotracheal tube.

5 5 Figure 4: Addition of Automatic Tube Compensation As the patient s acidemia resolved, the PPS settings were manipulated based on work of breathing, airway resistance, and compliance. Flow assist was set to 5.5 and Volume assist was adjusted to 12.0 by the next morning. The patient s peak inspiratory pressure, (PIP) had dropped from 30 to 12. Spontaneous tidal volumes were much more variable, and her spontaneous respiratory rate improved to the low 20/min.

6 6 PROPORTIONAL PRESSURE SUPPORT (PPS) Figure 5: Variable Tidal Volumes (Day 2) ABG RESULTS SHOW AN IMPROVED ACID BASE BALANCE: ph 7.38 PCO2 25 PO2 114 HCO BE -9.6 The patient was kept on PPS mode until she was alert. The clinical team believed that the patient could be extubated at this time. At this point the patient was placed on CPAP with pressure support for a brief spontaneous breathing trial and extubated.

7 7 Conclusion Proportional Pressure Support (PPS) can be a useful mode when the patient requires breath by breath adaption to support their own inspiratory demands, while unloading work of breathing. In this case, supporting the patient s spontaneous breathing in proportion to her effort allowed for effective management. Through the use of PPS, the clinicians were able to match the patient s respiratory demands and facilitate weaning from the ventilator. Brian Stewart has been a Respiratory Therapist since He is currently the Adult Critical Care Coordinator at Carle Foundation Hospital in Urbana, IL. His passion is to research potential therapies and seeing positive outcomes after bringing them into everyday practice.

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