Application of a Portable Home Ventilator for Treating Flail Chest After Cardiopulmonary Resuscitation: A Case Report

Background Case Conclusion


Abstract Background
Unexpected cardiopulmonary resuscitation and subsequent ail chest are rare in cardiac surgery patients.
A patient with a ail chest frequently requires long-term mechanical ventilator care. Early application of portable home ventilator (PHV) might be a useful treatment.

Case presentation
A 61-year-old female who underwent cardiac surgery had unexpected cardiopulmonary resuscitation with a ail chest. For treating her ail chest, portable home ventilator was applied with several respiratory rehabilitations.

Conclusion
We think PHV is useful and alternative treatment for inappropriate for surgical xation in ail chest patients.

Background
The incidence of unexpected cardiopulmonary resuscitation (CPR) after cardiac surgery is about 0.7-5.2%. It has reduced in recent years [1][2][3]. Skeletal chest injury after CPR can occur at a rate of 90%. The incidence of a ail chest after CPR is about 5% [4,5]. A patient with a ail chest frequently patient requires long-term mechanical ventilator care. Application of a portable home ventilator (PHV) is one last major step when treating patients who require long-term mechanical ventilation. For patients with ail chest, early application of PHV is important. Here, we present a case of a patient with a ail chest successfully treated with PHV.

Case Report
A 61-year-old Asian female patient was referred to our department with dyspnea and palpitation. The patient had been diagnosed with mitral stenosis (MS) 20 years previously. She was on medication. Severe MS and mild tricuspid valve regurgitation were con rmed by echocardiography. Atrial brillation was also observed on electrocardiogram. Based on the above ndings, the patient underwent mitral valve replacement, tricuspid valve annuloplasty, and mini-Maze. She was extubated and treated in a general ward. On the 12th postoperative day, the patient underwent pericardial window formation due to cardiac tamponade with large hematoma. Five days after the window operation, the patient had unexpected cardiac arrest and survived after 25 minutes of CPR. On the follow-up echocardiography, the replaced valve and cardiac function were normal. We attempted ventilator weaning and extubation twice. However, respiratory failure progressed due to a ail chest.
Chest wall reconstruction computed tomography was then conducted to evaluate the ail chest and for surgical planning (Fig. 1A, 1B). Right 3rd-7th and left 2nd-7th anterior arch of rib fractures and displaced sternum were observed. However, it was di cult to determine the surgical xation site because the ail segment was not prominent and the fracture displacement was not severe (Fig. 1C). Considering her nutritional state and previous two surgeries under general anesthesia, we decided to continue internal xation with ventilator care.
Tracheostomy was performed on the 19th day after CPR. After about 2 weeks of ventilator weaning, PHV was applied (Fig. 2) and the patient started respiratory rehabilitation including intermittent positive pressure ventilation, coughing machine, and diaphragmatic respiration. The patient was transferred to a general ward at 3 weeks after PHV application. On transfer to the general ward, the following settings were used: synchronized intermittent mandatory ventilation mode, O2 ow rate at 2 liter/minute, respiration rate of 8, and tidal volume of 350 ml.
PHV support and lung rehabilitation were continued for another three weeks. After chest wall stabilization and self-sputum toileting were con rmed, PHV weaning was done and the tracheostomy site was sealed off. Subsequently, the patient was discharged without any speci c ndings (Fig. 1D). She has been followed up at an outpatient clinic for three years. Currently, the patient activity is New York Heart Association classi cation I ~ II without any speci c problems. better results in terms of pneumonia incidence, intensive care unit (ICU) and hospital stays, lung function, and cost than the use of a ventilator [7][8][9][10]. However, surgical treatment has the disadvantage of exposing patients to surgical stress comparable to that caused by a traumatic event [9]. Furthermore, rib fractures after CPR tend to be underestimated by imaging, which can make it di cult to locate the prominent ail segment [7]. In addition, as seen in our case, general anesthesia and surgical treatment might be di cult for cardiac surgery patients due to hemodynamic instability, anticoagulant use, or previous sternotomy. In patients who have di culties after surgical treatment, the use of PHV might be a good alternative. Home ventilators are relatively easy to operate and portable. They can be applied in general wards. Early hospital application of PHV and general ward transfer have both short-term and long-terms bene ts. In a short term, PHV protects patients from severe ICU infections, reduces delirium, and facilitates treatment by increasing the range of rehabilitation treatments that can be applied. For patients requiring long-term ventilator care due to COPD, neuromuscular disease, skeletal disorder, or permanent damage to lung function due to trauma, in-hospital application of PHV can provide a useful adaptation period for patients and caregivers.

Disccussion And Conclusion
Recently, the use of noninvasive mechanical ventilation to avoid endotracheal intubation (ETI) has increased in the treatment of ail chest. Even if ETI and mechanical ventilation have been started, mechanical ventilation should be discontinued as soon as possible [11].
The importance of conservative treatment with rehabilitation and bedside treatment should not be overlooked. In the described case, respiratory rehabilitation was performed continuously, including intermittent positive pressure ventilation, coughing machine application, and diaphragmatic respiration. Bedside treatments such as manual percussion, encouraging ambulation, emotional support, and frequent respiratory toileting were also continuously performed or provided. Our patient was the rst to receive PHV for ail chest at our hospital. To be cautious, we observed her adaptation in the ICU for about two weeks after applying PHV. In the future, the adaptation period of PHV can be shorter.
In summary, we report a case of a patient with a ail chest after CPR. Her ail chest was successfully treated with a PHV and respiratory rehabilitation without any surgical treatment. We think that PHV is useful as an alternative treatment for patients with a ail chest after surgical xation.