Severe tbi patient successfully managed with pronation and inhaled epoprostenol for ARDS

Learning Objectives: Trauma patients are at high risk for acute respiratory distress syndrome (ARDS) due to direct (pulmonary contusion and aspiration) and secondary (multiple trauma, blood product transfusion, and non-cardiogenic shock) lung injury. Management of moderate to severe ARDS includes pronation and inhaled epoprostenol, with sparse literature evaluating these therapies in trauma patients. A case report follows of a severe traumatic brain injury (sTBI) patient with ARDS successfully treated with pronation and inhaled epoprostenol. Methods: A 21-year old, unhelmeted, male presented as a trauma alert after being hit by a car while riding his bicycle. Injuries included facial fractures, pulmonary contusion, and subdural hematomas (SDH) and right subarachnoid hemorrhage (SAH) with a midline shift. An emergent craniectomy was performed. Patient was awake, following commands on hospital day (HD) 1. The next few days the patient was intermittently agitation. On HD 7 the patient decompensated, chest x-ray showed bilateral opacities; a bronch was performed and antibiotics started. Post-bronch FiO2 remained 100% with a P/F of 50, a follow-up P/F was 66. There was concern of pronating due to the craniectomy site and missing bone flap. After discussion with the neurosurgeon, manual pronation was initiated with avoidance of the craniectomy site. Set-dose, 48-hour neuromuscular blockade plus inhaled epoprostenol were started. A one hour follow-up P/F was 189, deeming the patient a responder to inhaled epoprostenol. Prone therapy was discontinued on HD 11 with a P/F of 318. Inhaled epoprostenol was weaned over HDs 18 through 24. A therapeutic bronch was performed on HD 19, while in prone position to better facilitate pulmonary lavage. Tracheostomy and percutaneous endoscopic gastrostomy tube were placed on HDs 25 and 26, respectively. Aerosol trach collar trials began on HD 27; once fully freed from the ventilator on HD 40, the patient was transferred to the Trauma Step-Down Unit. Decannulation was completed on HD 44 with transfer to inpatient rehab on HD 46. Results: Patient was discharged home 9 days later. Three significant treatment options are highlighted: 1) safe pronation with a craniectomy; 2) inhaled epoprostenol for an extended amount of time; 3) feasibility of a bronch while prone.