Images in Clinical Medicine
Barotrauma
N Engl J Med 1998; 338:372February 5, 1998
- Article
Figure 1 A 44-year-old woman was admitted to the medical intensive care unit with acute respiratory distress syndrome due to Streptococcus pneumoniae infection. A chest radiograph taken soon after admission revealed diffuse bilateral infiltrates (Panel A). Mechanical ventilation was instituted with a fraction of inspired oxygen of 100 percent and a positive end-expiratory pressure of 15 cm of water. Static compliance was measured at 17 ml per centimeter of water, with peak airway pressures exceeding 50 cm of water. To minimize the risk of barotrauma, the mode of ventilation was changed from intermittent mandatory ventilation to pressure-controlled ventilation with a set inspiratory pressure of 35 cm of water. Two weeks after admission, however, tachycardia and marked hypertension suddenly developed. Examination revealed facial cyanosis, crisp heart sounds, and decreased but equal breath sounds bilaterally. Analysis of arterial-blood gases during pressure-controlled ventilation at a set rate of 20 per minute, an inspiratory pressure of 35 cm of water, a fraction of inspired oxygen of 100 percent, and a positive end-expiratory pressure of 12.5 cm of water revealed a pH of 7.19, a partial pressure of carbon dioxide of 101 mm Hg, and a partial pressure of oxygen of 40 mm Hg. A chest radiograph (Panel B) demonstrated large bilateral pneumothoraxes and pneumomediastinum (arrow). Chest tubes were placed bilaterally, with marked improvement in the patient's clinical status. The warning signs of barotrauma that often precede the findings in Panel B are shown in Panels C, D, and E. The deep-sulcus sign (arrow) in Panel C and the double-diaphragm sign (arrow) in Panel D are indicative of basilar pneumothoraxes. The chest radiograph in Panel E shows air below the left hemidiaphragm (arrow) that does not cross the midline, which is characteristic of pneumoretroperitoneum.
Helena Schotland, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104- Citing Articles (1)
Citing Articles
1
Nicolas Lellouche, Fabrice Bruneel, Francois Mignon, Nabil Ayoub, Gilles Troché, Pierre Guezennec, Bruno Priolet, Jean-Pierre Bédos. (2003) Pneumomediastinum causing pneumoperitoneum during mechanical ventilation. Journal of Critical Care 18:1, 68-69
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