ABDOMINAL COMPRESSION IN END-STAGE FIBROTIC INTERSTITIAL LUNG DISEASE (ILD) IMPROVES RESPIRATORY COMPLIANCE

ABSTRACT

SESSION TITLE Critical Thinking SESSION TYPE Case Reports PRESENTED ON 10/19/2022 0915 am - 1015 am INTRODUCTION: Compressive therapies to improve respiratory mechanics, such as abdominal compression, have been described in literature in patients with COVID-19 induced acute respiratory distress syndrome (COVID-19 ARDS) 1–3. These compressive therapies minimize the risk of barotrauma by equal distribution of pressure across the alveoli. Hence, they help with lung protective ventilation. This phenomenon of paradoxical improvement in respiratory compliance with increase in intraabdominal pressure (IAP) has not been described in ILD population. We describe a case of end-stage fibrotic ILD, secondary to hypersensitivity pneumonitis (HP), exhibiting a paradoxical improvement in respiratory compliance with sustained abdominal compression. CASE PRESENTATION 56-year-old female with history of NASH-related cirrhosis was transferred to our hospital for expedited work-up of lung transplant due to rapid progression of biopsy-proven steroid-unresponsive fibrotic HP. Due to worsening hypoxic respiratory failure, she was intubated on arrival to our hospital. Following intubation, she was sedated and paralyzed and was found to have high peak and plateau pressures in supine and reverse Trendelenburg positions. However, on application of abdominal pressure, her peak and plateau pressure showed a dramatic reduction in absolute values. This reduction was sustained during the entire duration of the maneuver. Overall, it reduced driving pressures and improved the static compliance of the respiratory system. We subsequently applied abdominal binder (table 1) and found a similar decrease in pressures (see images). Unfortunately, due to functional disability, patient was not deemed a candidate for lung and liver transplant and was transitioned to comfort measures. DISCUSSION: Paradoxical improvement in respiratory compliance has been demonstrated in late-stage COVID ARDS1,2. The mechanism behind this is unclear. In theory, increase in IAP increases intrapleural pressures, reduces end-expiratory volume and overdistention of aerated lung1,2. We hypothesize that patients with end-stage ILD behave similarly to patients with COVID-ARDS. However, this is purely exploratory as our observations are limited by lack of intrapleural measurements. Use of abdominal compression is a simple maneuver, which can be performed at the bedside to assess for the paradoxical phenomenon. Even though we postulate that long-term abdominal compression is well tolerated, we do not know the effects of sustained long-term abdominal compression on gas-exchange and chest wall dynamics. CONCLUSIONS: Patients with end-stage fibrotic lung disease, exhibiting high-driving pressures on mechanical ventilator in supine and reverse Trendelenburg positions, can be screened for reduction in peak and plateau pressures with abdominal compression. Use of this maneuver may help in lung-protective ventilation and minimize ventilator-induced lung injury. Reference #1 Elmufdi FS, Marini JJ. Dorsal Push and Abdominal Binding Improve Respiratory Compliance and Driving Pressure in Proned Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Explor. 2021;3(11)e0593. doi10.1097/cce.0000000000000593 Reference #2 Julia Cristina Coronado. Paradoxically Improved Respiratory Compliance With Abdominal Compression in COVID-19 ARDS. Is COVID-19 a risk factor Sev preeclampsia? Hosp Exp a Dev. 2020;(January)2020-2022. Reference #3 Stavi D, Goffi A, Shalabi M Al, et al. The Pressure Paradox Abdominal Compression to Detect Lung Hyperinflation in COVID-19 Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2022;205(2)245-247. doi10.1164/rccm.202104-1062IM DISCLOSURES No relevant relationships by Abhishek Bhardwaj No relevant relationships by Brandon Francis no disclosure on file for Marina Freiberg;No relevant relationships by Simon Mucha No relevant relationships by Arsal Tharwani