Page 694 - Clinical Application of Mechanical Ventilation

660 Chapter 19

own spontaneous tidal volumes increased. He was then weaned to CPAP only and
eventually extubated from CPAP to a face mask at 30% of oxygen.
A vigorous program of physical therapy was started to assist the patient with
overall strengthening of his weakened muscle. A dietary consult was obtained and a
metabolic study performed in order to adjust his feedings to appropriate nutritional
levels needed for successful weaning.
The patient was also started on albuterol Q 4° with postural drainage and percus-
sion. Antibiotics were used to treat the pneumonia. The patient was given neostig-
mine to manage his myasthenia gravis crisis.

NOTES: Adequate nutrition prior to and during weaning is necessary for a successful
outcome. Appropriate nutrition helps to maintain and build respiratory muscle mass and
strength, which enhances the likelihood of weaning.

Neostigmine (Prostig-
min) is an acetylcholinester- Complications
ase inhibitor. It is used to im-
prove muscle tone in people
with myasthenia gravis and Weaning attempts on this patient were complicated by three major factors: (1) my-
routinely in anesthesia at the
end of an operation, to reverse asthenia gravis, (2) aspiration pneumonia, (3) premature weaning attempts.
the effects of nondepolarizing The history of myasthenia gravis (a neuromuscular disease) inhibits the transmis-
neuromusclular blockers such
as rocuronium and ve- sion of nerve impulses at the myoneural junction. These patients typically have
curonium. chronic fatigability and weak muscles in the face and throat. They can also suffer
what is known as a myasthenia gravis crisis—an acute exacerbation of muscle weak-
ness that leads to respiratory distress and periods of apnea.
Myasthenia gravis,
aspiration pneumonia, and Aspiration pneumonia from the barium study increased the work of breathing
poor nutritional intake all and made it difficult for him to tolerate weaning procedures.
contributed to the failure of
earlier weaning attempts. Premature and inconsistent weaning attempts during the first 3 days of his hospi-
talization made subsequent weaning attempts more difficult.

CASE 11: GUILLAIN-BARRÉ

INTRODuCTION

K.D. was a 14-year-old, 49-Kg, right-handed male who sustained two minor head
injuries at school over a period of one week. One injury occurred while playing basket-
ball when a heavier student fell on him, and the other occurred in an altercation during
a break from school. Neither injury resulted in the loss of consciousness. He presented
to the clinic complaining of headache and back pain but did not complain of slurred
®
speech until being started on pain medication (Dolobid ) one day prior to admission.
His medical history is noncontributory and consists of one hospitalization for a hernia
repair in the distant past. He denied blurred vision but admitted to having transient
nausea and had recently refused food. Since his slurred speech had become more
pronounced than on his previous examination, he was admitted for further evaluation.

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