improvement-of-acute-respiratory-distress-syndrome-with-ethyl-alcohol-

Views:
 
     
 

Presentation Description

Acute respiratory distress syndrome (ARDS) can arise due to various causes and is often seen in patients with traumatic haemorrhagic shock. The prognosis of patients with ARDS remains poor, and the respiratory management of these patients involves numerous difficulties.

Comments

Presentation Transcript

slide 1:

Volume 8 • Issue 3 • 1000464 J Pulm Respir Med an open access journal ISSN: 2161-105X Journal of Pulmonary Respiratory Medicine ISSN: 2161-105X Journal of Pulmonary Respiratory Medicine Takahashi and Endo J Pulm Respir Med 2018 8:3 DOI: 10.4172/2161-105X.1000464 Case Report Open Access Improvement of Acute Respiratory Distress Syndrome with Ethyl Alcohol Infusion into the Airway: A Case Report Takahashi G 1 and Endo S 2 1 Department of Critical Care Disaster and General Medicine School of Medicine Iwate Medical University Morioka Japan 2 Morioka Yuai Hospital Morika Japan Abstract Background:This case involves a male in his late thirties who was transported from another institution to our hospital in a state of haemorrhagic shock after receiving severe injuries in a traffc accident. Case Presentation: After hospitalisation and artifcial respiration under sedation his respiratory condition worsened on the 2 nd hospital day and he was diagnosed with acute respiratory distress syndrome ARDS with an arterial oxygen partial pressure to fractional inspired oxygen PaO 2 /FiO 2 P/F ratio of ≤ 300. A large amount of bloody foamy sputum was expectorated on the 4 th hospital day and his P/F ratio decreased to 44 the amount of sputum did not reduce even after implementing sputum suction every 3-5 min. We considered introducing an extracorporeal membrane oxygenation device but because it was an emergency situation with 80 of percutaneous oxygen saturation we instead performed suction operation several times immediately after injecting 10 cc of ethyl alcohol 76.9 to 81.6 vol into the pulmonary alveoli. Subsequently bloody foamy sputum expectoration was suddenly decreased and the patient recovered from ARDS on the 7 th hospital day with a marked improvement in his P/F ratio. Conclusions: We have reported the implications of our continuous measurement for neutrophil elastase interleukin 8 and surfactant protein D in blood and sputum as well as how these metrics related to the patient’s respiratory state. Corresponding author: Gaku Takahashi Division of Critical Care Medicine Department of Critical Care Disaster and General Medicne School of Medicine Iwate Medical University 19-1 Uchimaru Morioka 020-8505 Japan Phone: +81- 19-651-5111 Fax: +81-19-651-5151 E-mail: gakutiwate-med.ac.jp Received July 17 2018 Accepted July 24 2018 Published July 31 2018 Citation: Takahashi G Endo S 2018 Improvement of Acute Respiratory Distress Syndrome with Ethyl Alcohol Infusion into the Airway: A Case Report. J Pulm Respir Med 8: 464. doi: 10.4172/2161-105X.1000464 Copyright: ©2018 Takahashi G et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use distribution and reproduction in any medium provided the original author and source are credited. Keywords: Acute respiratory distress syndrome Respiratory status PaO 2 /FiO 2 ratio Abbreviations: ARDS: Acute Respiratory Distress Syndrome ECMO: Extracorporeal Membrane Oxygenation IL-8: Interleukin 8 PaO 2 /FiO 2 P/F ratio: Arterial Oxygen Partial Pressure to Fractional Inspired Oxygen Ratio SP-D: Surfactant Protein D Background Acute respiratory distress syndrome ARDS can arise due to various causes and is ofen seen in patients with traumatic haemorrhagic shock 1. Te prognosis of patients with ARDS remains poor and the respiratory management of these patients involves numerous difculties. In ARDS cases the activation of infammatory cells such as neutrophils against invasion leads to vascular endothelial and alveolar epithelial cell injuries which produces enhanced vascular permeability thus resulting in pulmonary oedema. We have previously reported the efcacy of alveolar lavage with ethyl alcohol in a case of post-multiple fracture ARDS encountered by us which was difcult to treat and also discussed its relationship with neutrophil elastase and interleukin 8 IL-8. We recently encountered another case of ARDS in a similar trauma patient wherein ethyl alcohol administration into the pulmonary alveoli dramatically improved the patient’s respiratory status. Te blood and sputum levels of neutrophil elastase IL-8 and surfactant protein D SP-D elaborated by type II alveolar epithelial cells 2 were consecutively measured to assess their relation to the respiratory status. Case Presentation Te patient was a male in his late thirties with an unremarkable family history. At about 6 am the patient was driving a heavy truck that happened to skid on a frozen road surface and that track fell to a clif beneath about 15 meters. Te patient’s legs were trapped beneath the dashboard of the truck and he was rescued approximately 4 h later. He was rushed to a nearby hospital and then transferr ed to our hospital 3 h later about 8 h afer the injury. On admission the systolic pressure was about 80 mm Hg clearly indicating haemorrhagic shock. While the patient was receiving an emergency blood transfusion imaging examinations to assess the extent of injuries were performed. He was found to have a fracture of the pelvis an open fracture of the right femur right lower leg fractures an open fracture of the lef femur and open fractures of the lef lower leg bones. No trauma was seen on the head chest or abdomen. Te systolic pressure improved to 100 mm Hg approximately 1 h afer his arrival at our hospital. Fracture treatment was then initiated and the patient was admitted to the intensive care unit. At that time there was no clinical sign of concern regarding his respiratory status and his arterial oxygen partial pressure to fractional inspired oxygen PaO 2 /FiO 2 P/F ratio was 322 Figure 1A while the systolic pressure was consistently maintained at 110-120 mm Hg. However on the 2 nd hospital day his breathing rapidly became laboured he was intubated and mechanical ventilation was initiated since his P/F ratio became ≤ 300. On echocardiography there was no decline in the lef ventricular ejection fraction or expansion of the lef atrium however bilateral infltration shadows were observed in his chest X-ray which were diagnostic of ARDS Figure 1B. A large amount of bloody foamy sputum was expectorated on the 4 th hospital day and his P/F ratio decreased to 44. Te amount of sputum was not reduced even afer implementing sputum suction every 3-5 min along with corticosteroid administration and other measures such as modifcation of mechanical ventilation parameters. During the night of the 4 th hospital day we

slide 2:

Citation: Takahashi G Endo S 2018 Improvement of Acute Respiratory Distress Syndrome with Ethyl Alcohol Infusion into the Airway: A Case Report. J Pulm Respir Med 8: 464. doi: 10.4172/2161-105X.1000464 Page 2 of 4 Volume 8 • Issue 3 • 1000464 J Pulm Respir Med an open access journal ISSN: 2161-105X serum neutrophil elastase levels over time. Nevertheless the sputum neutrophil elastase levels were one order of magnitude higher than the blood neutrophil elastase levels possibly implying that a large amount of neutrophil elastase is produced at the site of infammation. Te serum IL-8 level which has neutrophil-activating properties also changed in parallel with the blood serum and sputum neutrophil elastase levels over time suggesting the possible involvement of IL-8 in the production of neutrophil elastase which is consistent with our fnding in a previous study 4. We have also reported the possible involvement of neutrophil elastase in the impairment of the pulmonary surfactant 67 which is synthesised in and secreted from alveolar type II epithelial cells that cover the inner surfaces of the alveoli to prevent end-expiratory alveolar collapse 5. Te inhibition of this pulmonary surfactant activity by proteins in various lung oedema fuids is believed to be involved in the development of respiratory failure in ARDS. Even in this extreme case the inhibitory action of SP-D on the pulmonary surfactant showed a high value at the onset of ARDS and the acuteness of the situation decreased with improvement in the patient’s respiratory condition. Although the mechanism of improvement of oxygenation capacity in this case is not clear no reports have indicated that ethyl alcohol suppresses the production of IL-8 and neutrophil elastase. Terefore there is little evidence to infer that decreasing these values will directly improve respiratory function. In our case as reported by Luisada et al. the surface tension of the moisture coating on the alveolar surface was directly reduced by ethyl alcohol injection with very low surface tension and alveolar collapse was improved while the formation of foam was suppressed. As a result the ejection of bloody foamy sputum decreased and oxygenation improved. Further the production of IL-8 and neutrophil elastase decreased and the damage to the pulmonary surfactant was also suppressed. As an animal experiment in 1993 Waugh reported the efect of inhalation of alcohol vapor using rabbits drowning models. Since the alveolar edema improved with the same mechanism as reported by Luisada et al. Te oxygenation ability was signifcantly improved in the group inhaling alcohol vapor compared to the group in which water vapor was inhaled 8. considered introducing an extracorporeal membrane oxygenation ECMO device because this was an emergency situation with 80 of percutaneous oxygen saturation. However since it takes about 2 h to implement such a step during the night shif we conducted the suction procedure several times afer injecting 10 cc of ethyl alcohol 76.9 to 81.6 vol into the pulmonary alveoli at once as an emergency measure against hypoxic encephalopathy Figure 1C. Fortunately this was followed by a dramatic decrease in the amount of bloody foamy sputum produced. Te procedure was repeated once approximately 10 min later. Following the second administration of ethyl alcohol there was little or zero production of bloody foamy sputum and percutaneous oxygen saturation improved to approximately 90 therefore ethyl alcohol was not administered further. Bilateral infltrative shadows in the chest X-ray markedly improved on the 6 th hospital day. Te P/F ratio exceeded 300 and the patient recovered from ARDS on the 7 th hospital day Figure 1D. During the time when he manifested the signs of ARDS the patient’s serum neutrophil elastase level was 1770 ng/mL sputum neutrophil elastase level was 19700 ng/mL serum IL- 8 level was 1210 pg/mL and serum SP-D level was 670 ng/mL that is the levels of all parameters were worryingly elevated. Remarkably in response to the treatment his serum and sputum neutrophil elastase levels as well as serum IL-8 and SP-D levels decreased almost simultaneously along with a marked increase in the P/F ratio Figure 2. Te patient also received a one-stage open reduction for his numerous fractures. He was transferred to another hospital for rehabilitation at 3 weeks afer this surgery where he was under a rehabilitation programme for about 4 months he was discharged home with practically no disability. Discussion For this case the frequent suction of profuse amounts of bloody foamy sputum and modifcation of positive end-expiratory pressure PEEP 5 to 15 mmHg and tidal volume 300 to 650 mL performed over approximately 2 h failed to reduce the tremendous amount of sputum discharge. We administered ethyl alcohol in this situation in line with a report of improvement in oxygenation resulting from a reduction of surface tension within the alveoli by ethyl alcohol inhalation and also in the light of gratifying results obtained through intra-tracheal ethyl alcohol infusion in a case of ARDS similar to ours. Te results produced in the case documented herein clearly confrm the reproducibility of the response observed in these earlier reports 2. Although it is uncertain how deep the ethyl alcohol injected in the vicinity of a tip of an endotracheal tube can reach within the alveolar spaces of the lung this procedure possibly exerted a defnite efect as the bloody foamy sputum secretion rapidly diminished afer ethyl alcohol administration. In response to challenges such as traumas infammatory cytokines and many other mediators elaborated in the body 3 the stimulated neutrophils produce large amounts of proteolytic enzymes such as neutrophil elastase. Tese factors are considered to have a profound bearing on the pathophysiological state of progression into multi- organ failure including ARDS 45. Neutrophil elastase has an extremely potent proteolytic enzyme activity and can reduce all constituent proteins of the body. In our case the serum neutrophil elastase level was markedly elevated when the patient had ARDS. Te sputum neutrophil elastase levels were also found to be elevated and eventually changed in parallel with the blood Figure 1: Chest X-ray in progress.

slide 3:

Citation: Takahashi G Endo S 2018 Improvement of Acute Respiratory Distress Syndrome with Ethyl Alcohol Infusion into the Airway: A Case Report. J Pulm Respir Med 8: 464. doi: 10.4172/2161-105X.1000464 Page 3 of 4 Volume 8 • Issue 3 • 1000464 J Pulm Respir Med an open access journal ISSN: 2161-105X Even in the study we previously conducted 200 μl of distilled water was dropped on a waterproof surgical cloth to form a sphere and when a small amount of ethyl alcohol was dropped on to it the sphere immediately fattened and the surface tension decreased Figure 3. It was also confrmed that the foam began disappearing immediately even when a small amount of ethyl alcohol was sprayed on a foam cleanser detergent completely disappearing in about 10 s Figure 4. Since it is extremely uncommon to encounter a case like ours it is difcult to accumulate relevant evidence. However the gratifying outcomes obtained by us in two cases including the present one suggests the potential efcacy of ethyl alcohol infusion in such circumstances. Also no adverse reactions were encountered. Te optimal dose of ethyl alcohol the optimal timing of its administration and the optimal method of its administration are yet to be fully explored. Regarding the intra-tracheal injection of ethyl alcohol considering the time required for introducing ECMO it was decided that the risk of hypoxic encephalopathy would be increased therefore it was clearly explained to the family that it was an unauthorised method and it was used only afer obtaining consent. As far as we could search since the report of Boxman in 1958 we have not found a report used on the human body and the safety and efectiveness are not sufciently verifed as a treatment method 9. We never choose an evidence-free treatment. We would like the readers to understand that this case was an emergency situation. Conclusion By administration of ethyl alcohol into the pulmonary alveoli the amount of bloody foamy sputum decreased markedly and afer that Figure 2: Blood or sputum levels of various humoral factors arterial oxygen partial pressure to fractional inspired oxygen PaO2/FiO2 P/F ratio and chest X-ray fndings over time following admission. Figure 3: 200 μl of distilled water was dropped on a waterproof surgical cloth to form a sphere and when a small amount of ethyl alcohol was dropped onto it the sphere immediately fattened and the surface tension decreased. Figure 4: The foam began disappearing immediately even when a small amount of ethyl alcohol was sprayed on the foam cleanser detergent completely disappearing in about 10 s.

slide 4:

Citation: Takahashi G Endo S 2018 Improvement of Acute Respiratory Distress Syndrome with Ethyl Alcohol Infusion into the Airway: A Case Report. J Pulm Respir Med 8: 464. doi: 10.4172/2161-105X.1000464 Page 4 of 4 Volume 8 • Issue 3 • 1000464 J Pulm Respir Med an open access journal ISSN: 2161-105X the respiratory condition improved as well. Each marker markedly decreased with the improvement of P/F ratio. Availability of Data and Material Te data generated and analyzed in this study are included in this published article and its additional fles. Te original datasets used for this study are not publicly available due to the existing regulation and only can be shared upon the approval of the directors of the corresponding hospitals. References 1. Bernard GR Artigas A Brigham KL Carlet J Falke K et al. 1994 The american-european consensus conference on ARDS. Defnition mechanisms relevant outcomes and clinical trial coordination. Am J Respir Crit Care Med 149: 818-824. 2. Nakae H Endo S Yaegashi Y Go W Imai S et al. 2004 Surfactant protein-D and polumorphonuclear leukocyte elastase concentratios in patients with septic acute respiratory distress syndrome. Crit Care Shock 7: 159-163. 3. Luisada AA Goldmann MA Weyl R 1952 Alcohol vapor by inhalation in the treatment of acute pulmonary edema. Circulation 5: 363-369. 4. Endo S Inada K Yamada Y Takakuwa T Kasai T et al. 1994 Plasama endotoxin and cytokine Levels in patients with hemorrhagic shock. Crit Care Med 22: 949-955. 5. Endo S Inada K Ceska K Takakuwa T Yamada Y et al. 1995 Plasma interleukin 8 and polymorphonuclear leukocyte elastase concentrations in patients with septic shock. J Infamm 45: 136-142. 6. Nakae H Endo S Takakuwa T. 1995 Relationship between alpha-tocopherol and polymorphonuclear leukocyte elasatase in septic adult respiratory distress syndrome. Res Commun Molecul Pathol Pharmacol 89: 93-100. 7. King RJ Clements JA 1972 Surfactant active materials from dog. II. Composition and physiological correlations. Am J Physiol 223: 715-726. 8. Waugh WH 1993 Potential use of warm butyl alcohol vapor as adjunct agent in the emergency treatment of sea water wet near-drowing. Am J Emerg Med 11: 20-27. 9. Boxman D 1958 Alcohol vapor in the emergency treatment of acute pulmonary edema. J Am Osteopath Assoc 57: 659-661.

authorStream Live Help