Respiratory system mechanics in the early phase of acute respiratory failure due to severe kyphoscoliosis

Objective: To evaluate respiratory mechanics in the early phase of decompensation in a group of seven patients with severe kyphoscoliosis (KS) (Cobb angle > 90 °) requiring mechanical ventilatory support. Design: Prospective clinical study with a control group. Setting: General intensive care unit at University of Rome “La Sapienza”. Patients: Seven consecutive patients affected by severe KS in the early phase of acute decompensation and a control group of six ASA (American Society of Anesthesiology) 1 subjects who were mechanically ventilated during minor surgery. Measurements and results: Respiratory mechanics were evaluated during constant flow-controlled mechanical ventilation at zero end-expiratory pressure with the end-inspiratory and end-expiratory occlusion technique. In five patients who showed increased ohmic resistance (RRSmin), we evaluated the possibility of reversing this increase with a charge dose of 6 mg/kg doxophylline i. v. In four KS patients, in whom a reliable esophageal pressure was confirmed by a positive occlusion test, we separated respiratory system data into lung and chest wall component. All KS patients showed reduced values of respiratory compliance (CRS) and increased respiratory resistance (RRS). The average basal values of CRS were 36 ± 10 vs 58 ± 8.5 cmH2O in control patients; RRSmax was 20 ± 3.1 vs. 4.5 ± 1.2 cmH2O/l per s; RRSmin 6.2 ± 1.2 vs. 2 ± 0.5 cmH2O/l per s: ΔRRS 14 ± 2.6 cmH2O vs 2.4 ± 0.7 cmH2O/l per s. All KS patients showed low values of intrinsic positive end-expiratory pressure (PEEPi) (1.8 ± 1.5 cmH2O). Separation of lung and chest-wall mechanics, performed only in four patients, showed a reduction in both lung (66.7 ± 7.2 ml/cmH2O) and chest wall values (84 ± 8.2 ml/cmH2O), while both RmaxL and RmaxCW were increased (16.6 ± 2 and 2.8 ± 0.4 cmH2O/l per s, respectively). Infusion of doxophylline did not significantly change respiratory mechanics when evaluated 15, 30, and 45 min after the infusion. Conclusions: During acute decompensation, both lung and chest-wall compliance are severely reduced in KS patients: conversely, and, contrary to that in patients with chronic obstructive pulmonary disease, increases in airway resistance and PEEPi seem to play only a secondary role.