Global Journal of Pathology and Microbiology, 2017, 5, 33-35 33

ISSN: 2310-8703/17 © 2017 Synchro Publisher

Cause Of Unsuccessful Weaning In Chronic Obstructive Pulmonary Disease Patient: Mucus Plug

Hakan Aygun1, Cem Ece1,* and Serdar Sirzai2

1Cigli Regional Education Hospital, Department of Anesthesiology and Reanimation, Izmir, Turkey 2T.E.V. Sultanbeyli State Hospital, Department of Thoracic Surgery, Istanbul, Turkey

Abstract: Spontaneous respiration starts when the patient is separated from the mechanical ventilation device.

It is reported that patients with chronic obstructive pulmonary disease (COPD) have lower success in separation from the mechanical ventialtor (weaning). In this case report we presented a patient hospitalized at the intensive care unit that did not have succesful weaning and have been extubated after aspiration of the mucus plug by bronchoscopy. Mucus plug should be kept in mind as a factor in weaning after elimination of all other causes. We think that bronchoscopy as reported in this case is an effective method in diagnosis and monitoring of the patients at intensive care units.

Keywords: COPD, mucus plug, weaning, bronchoscopy.

1. INTRODUCTION

Weaning is defined as gradually decreasing and stopping the mechanical ventilation support. Successful weaning is reported as having spontaneous respiration more than 48 hours without the mechanical ventilation support. Many factors such as metabolic imbalance, insufficient nutrition, heart failure, hypothyroidism, electrolyte imbalance, infection may affect the weaning success. The lung capacity has decreased in Chronic obstructiv lung disease (COPD). Because of this weaning is harder in these patient groups [1]. In this case report we aimed to present weaning problem due to mucus plug.

2. CASE

59 year old male patient with a history of COPD and congestive heart failure (CHF) for eight years was admitted to the emergency room due to progressive dyspneae. In his chest X-ray cardiothoracic index increment and opacity increase with sinus closure and demossi line were detected. Arterial blood gas analysis revealed pH: 7.643 partial oxygen pressure (PaO2): 45,1 mmHg, partial carbondioxide pressure (PCO2): 25,2 mm Hg. The patient was transferred to coronary intensive care unit with a prediagnosis of pulmonary edema and general condition disorder due to congestive heart failure and low ejection fraction in echocardiography. Intensive care unit monitorization revealed hypoxia, hypercapnia, and tachypneae. The patient underwent mechanical ventialation support. The patient was cooperative, conscious and entubated with

*Address correspondence to this author at the Cigli Regional Education Hospital, Department of Anesthesiology and Reanimation, Izmir, Turkey; E-mail: cemece.dr@gmail.com

mechanical ventilator and weaning was unsuccesful. The patient was transferred to a tertiary care Anesthesiology Intensive Care Unit. The physical examination revealed bilateral pretibial edema, decreased lung sound at lower zones, and ronchus. The patient was cooperative, hemodynamically stable; but all three weaning trials were unsuccessful at this unit. The thorax computerized tomography showed a lesion on the lateral wall of the tracheae extending to the left main bronchus (Figure 1). Multiple biopsies were taken from the lesion that was 80% narrowing the tracheal lumen during bronchoscopy procedure (Figure 2). The pathology report indicated the lesion as

condensed mucus with neutrophil and lymphocyte clusters. No elevation was detected in infectious makers neither in leukocyte count. Third generation cephalosporin treatment was stopped on the 7th day of hospitalization. No abnormality was detected in routine

Figure 1: The thorax computerized tomography showing a lesion on the lateral wall of the tracheae extending to the left main bronchus.

34 Global Journal of Pathology and Microbiology, 2017, Vol. 5 Hakan, et al.

assays. On the 20th day of intubation mucus plug was degraded by hard aspirations during bronchoscopy. After this procedure the weaning was successfully completed on the 21st day and the patient was extubated.

3. DISCUSSION

Acute respiartory failure due to COPD is a serious health problem and economic cost. Mechanical ventilation is a life saving method in COPD patients with acute respiratory failure; but ventilator associated pneumoniae, respiratory truct destruction, barotrauma and weaning failure are important complications [2]. Separation from the mechanical ventilator is called weaning. There are various parameters for prediction of weaning and it takes 40% of the total duration spent during ventilation and it is a tough process [3]. Weaning failure is higher in COPD patients and varies between 35%-65% [4].

Weaning depends on a lot of factors in different studies. APACHE-II score, sedation application and its duration, Glasgow score, arterial blood gas analysis parameters, electrolyte values, cardiovascular and hemodynamic stability, inotrop requirement, sepsis and infection are affecting parameters [5,6,7,8,9].

In this case report the mucus plug of the patient was destroyed and aspirated during the bronchoscopy procedure and after this successful weaning and extubation were performed. There is no literature indicating the mucus plug as a cause of weaning failure. Because of that mucus plug should be evaluated as a factor in weaning failure after eliminating all the other reasons. We also think that bronchoscopy use in intensive care units is an effective method in diagnosis and treatment. Ventilator dependency is defined as failure of separation from the device for three months against weaning trials except in irreversible diseases such as spinal cord destruction, amoytrophic lateral sclerosis. In this case report although elimination of other factors have been done, still a successful weaning procedure could not take place during less than a three month period.

REFERENCES

[1] MacIntyre NR, Cook DJ, Ely EW Jr, Epstein SK, Fink JB, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians, the American Association for Respiratory Care, and the American College of Critical Care Medicine. Chest 2001; 120(Suppl): 375S-395S. Also in: Respir Care 2002; 47(1): 69-90.

Figure 2: Mucus plug.

Cause Of Unsuccessful Weaning In Chronic Obstructive Pulmonary Disease Patient: Global Journal of Pathology and Microbiology, 2017, Vol. 5 35

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[8] Khamiees M, Raju P, DeGirolamo A, et al. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001; 120(4): 1262-70. https://doi.org/10.1378/chest.120.4.1262

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Received on 20-12-2017 Accepted on 28-12-2017 Published on 31-12-2017 DOI: http://dx.doi.org/10.20941/2310-8703.2017.05.5

© 2017 Hakan, et al.; Licensee Synchro Publisher. This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.