PMC5304242_01
CT imaging taken at initial admission to the primary hospital. The image showed miliary opacities.
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X-ray and CT imaging were assessed as bilateral tree-in-bud sign (Fig. 1).
Trans-pulmonary pressure (PTP) waveforms before (A), during (B) and after (C) onset of rocuronium infusion. Before administration of rocuronium, the alternating spontaneous breaths and mandatory breaths are visible. During the spontaneous breaths, the PTP rises to values beyond 35 cmH2O. During the onset of rocuronium infusion the PTP during spontaneous breaths quickly reduces in amplitude. After a few breaths, spontaneous effort seems to disappear completely, decreasing the peak PTP to 19 cmH2O. The PTP at end-expiration increases from -9 cmH2O to -2 cmH2O.
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The patient had persisting spontaneous efforts in a 1:2 ratio: one spontaneous effort during every second mandatory breath (Fig. 2A). PTP was calculated. PTP was 34 cmH2O during inspiration and -9 cmH2O at end expiration (Fig. 2A). PEEP of 18 cmH2O and peak airway pressure of 28 cmH2O. PTP decreased from 34 to 19 cmH2O during inspiration and PTP increased from -9 to -2 cmH2O at end of expiration (Fig. 2B and C).
EIT ventilation distribution map before and after administration of rocuronium. The image represent a transverse plane at the level of the 5th intercostal space. Anatomical positioning is equal to CT imaging. Dark grey areas indicate no ventilation. White areas indicate high TIV, with decreasing TIV towards darker colors. (a) The fraction of regional TIV before administration of rocuronium was 25% and 75% in the non-dependent and the dependent regions, respectively. (b) After administration of rocuronium, global TIV decreased to 35% of that of before administration. The fraction of distribution of global TIV after rocuronium administration was 43% and 57% in the non-dependent and the dependent regions, respectively. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)
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Simultaneously electrical impedance tomography (EIT) measurements were performed at the 5th intercostal space (Fig. 3).
Intratidal gas distribution (a) before and (b) after administration of rocuronium. The intratidal gas distribution describes the regional gas distribution during an inspiration. The global tidal impedance changes were divided into eight iso-volume sections. The corresponding time points of the eight iso-volume steps are translated to the regional TIV changes and the percentile contribution of the dependent and non-dependent regions was calculated and plotted. (a) The graph shows the predominant distribution of inspired gas to the dependent part during an almost entire inspiratory phase. (b) Inspired gas distributed equivalently to both parts of the lungs after administration of rocuronium. Dashed lines represents the interpolation lines; open circles = non-dependent region; solid circles = dependent region.
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TIV decreased by 65% and was more homogeneously distributed (Fig. 4).