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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 43-45

Acute respiratory distress syndrome following near drowning: A case report and review of literature


Department of Respiratory Medicine, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Date of Submission07-Jun-2021
Date of Decision16-Jun-2021
Date of Acceptance19-Jul-2021
Date of Web Publication22-Sep-2021

Correspondence Address:
Jan Rexie Mathew
No. 8, Kanaga Selvi Bhavanam, Thendral Nagar, Srinivasa Nagar, Tirunelveli - 627 011, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/japt.japt_26_21

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  Abstract 


According to the World Health Organization, drowning is the third leading cause of unintentional injury death worldwide, accounting for 7% of all injury-related deaths. National Crime Records Bureau estimates an average of 83 deaths every day in India due to drowning. A 36-year-old male, who is a known case of posttraumatic seizure disorder, was admitted with an alleged history of drowning into the river. On admission, the patient had severe hypoxemia and chest X-ray revealed bilateral diffuse heterogeneous fluffy infiltrates suggestive of acute respiratory distress syndrome (ARDS). The patient was immediately intubated and mechanically ventilated. Subsequent computed tomography imaging of the patient showed mixed areas of consolidation and ground-glass opacities. Later in the course of stay in the hospital, the condition of the patient gradually improved and he was discharged from the hospital in a stable condition. The outcome of ARDS in drowning victims is better when compared to the ARDS of other etiologies.

Keywords: Acute respiratory distress syndrome, incidence, management, near drowning, noninvasive and invasive ventilation


How to cite this article:
Mathew JR, Krishnamoorthy K. Acute respiratory distress syndrome following near drowning: A case report and review of literature. J Assoc Pulmonologist Tamilnadu 2021;4:43-5

How to cite this URL:
Mathew JR, Krishnamoorthy K. Acute respiratory distress syndrome following near drowning: A case report and review of literature. J Assoc Pulmonologist Tamilnadu [serial online] 2021 [cited 2022 Jan 28];4:43-5. Available from: http://www.japt.com/text.asp?2021/4/1/43/326412




  Introduction Top


Drowning is the process of experiencing respiratory impairment from immersion/submersion in liquid. Drowning outcomes are fatal or nonfatal. In nonfatal drowning, the process of respiratory impairment is stopped before death. Acute respiratory distress syndrome (ARDS) in a victim of drowning is mainly due to a direct toxic effect of water on the lung epithelium.[1]

In this article, we report a case of near drowning and subsequently discuss the pathophysiology and management of ARDS in a victim of drowning.


  Case Report Top


A 36-year-old male, who is a known case of posttraumatic seizure disorder on anti-epileptic drugs was brought to the hospital by the bystanders with an alleged history of drowning into the river. On admission in the intensive care unit, the patient was drowsy with a Glasgow Coma Scale (GCS) of 10/15 and his oxygen saturation (SpO2) was 55% at room air, temperature was 98.9 F, pulse rate - 101/min, heart rate - 32/min, and blood pressure - 120/70 mmHg. Auscultation of RS – bilateral inspiratory and expiratory coarse crepitations. Arterial blood gas (ABG) - decompensated respiratory acidosis with severe hypoxia, chest X-ray revealed bilateral diffuse heterogeneous opacities suggestive of ARDS [Figure 1]. In view of falling saturation and poor GCS, the patient was intubated immediately and mechanically ventilated with the following initial settings:
Figure 1: Bedside CXR on the day of admission shows bilateral diffuse coalescent opacities suggestive of ARDS

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  • Low tidal volume of 6 ml/kg of predicted body weight
  • Ventilator mode: Volume assist control mode
  • FiO2: 1.0
  • Positive end-expiratory pressure (PEEP): 10 cm H2O
  • Target Pplat: ≤30 cmH2O.


The patient was clinically assessed for the next 4 h for improvement in gas exchange by means of ABG (PaO2) and SpO2 of hemoglobin.

The patient's condition drastically improved and after a period of 24 h the FiO2 was gradually tapered, PEEP was reduced and the ventilator mode was changed to synchronized intermittent mandatory ventilation. The patient was able to maintain a target PaO2 of 55–80 mmHg and SpO2 of 88%–95%.

The patient's response to the treatment was closely monitored and his readiness to be weaned off from the mechanical ventilation was assessed periodically by rapid shallow breathing index (RSBI). After a period of 72 h, when the RSBI was found to be <105, the patient was extubated after a successful 30 min spontaneous breathing trial. He was then put on CPAP for the next 3 days. CT chest of the patient revealed mixed areas of ground-glass opacities and patchy consolidation [Figure 2], [Figure 3], [Figure 4]. Later in the course of stay, the condition of the patient improved and he was shifted to the ward and was on O2 support through the nasal cannula for the next 4 days. He was then completely weaned off from O2 support and was discharged in stable condition.
Figure 2: CT Chest images of the same patient showing bilateral , asymmetrical patchy areas of dense consolidation merging into a background of Ground glass attenuation , predominantly over the lower lung fields

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Figure 3: CT Chest images of the same patient showing bilateral , asymmetrical patchy areas of dense consolidation merging into a background of Ground glass attenuation , predominantly over the lower lung fields

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Figure 4: CT Chest images of the same patient showing bilateral , asymmetrical patchy areas of dense consolidation merging into a background of Ground glass attenuation , predominantly over the lower lung fields

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  Discussion Top


Objective

The objective of this study is to discuss the pathophysiology and management of ARDS following drowning.

Pathophysiology

Every drowning patient is characterized by arterial hypoxemia. The severity of hypoxemia depends on the stage of drowning. Three stages of drowning have been recognized. In stage 1 (in <10% of patients), there is no water aspiration but only a severe laryngospasm which blocks the passage of air and lung ventilation. Consequently, the inspiratory effort, creating a negative alveolar pressure may cause pulmonary edema. In Stage 2 and 3, in which there is water aspiration, there is an alteration of the pulmonary surfactant, damage to the alveolar-capillary endothelium, and alveolar flooding. The combination of these factors favor the increase in lung mass, the formation of lung compressive atelectasis, decrease in lung compliance, with an increase of pulmonary shunt and dead space.[2],[3]

Management

The primary goal in every drowning victim is to ensure an adequate oxygen delivery by means of artificial ventilation.

Noninvasive positive pressure ventilation

If the PaO2/FiO2 ratio is lower than 200 mmHg or the respiratory rate is higher than 24 beats/min with severe dyspnea and use of accessory muscles, noninvasive positive pressure ventilation (NPPV) should be started. However, NPPV can be applied only in conscious patients, with good airway reflexes and in whom gas exchange impairment is mild.

CPAP is the most common and easy way to deliver NPPV. During CPAP, the PEEP level should be increased to reach at least an arterial saturation above 90% with the lowest possible level of the inspired oxygen fraction.[2]

Invasive mechanical ventilation

When NPPV fails to correct gas exchange within the 1st h, invasive mechanical ventilation should be started. Invasive mechanical ventilation should be promptly applied in comatose patients or in case of severe gas exchange impairment.[4],[5],[6]

In the early phase of ARDS, when using invasive mechanical ventilation, the following five objectives should be applied.

Recruit the lung

The aim is to reopen the atelectasis lung regions. Different types of recruitment maneuvres have been proposed such as the application of CPAP at 40 cmH2O for 40 s, or the use of pressure-controlled ventilation set to reach 40 − 45 cmH2O.

Keep the lung open

An adequate level of PEEP must be applied to oppose the critical closing pressure. PEEP could also translocate edema fluid from airways and alveoli to the interstitial perivascular space.

Select the right positive end-expiratory pressure level

The optimal PEEP is defined as: “the level of PEEP required to minimize the intrapulmonary shunt with minimal negative effects on cardiac output.” The most common method to select PEEP is the gas exchange trial. Different PEEP levels from 5 to 15 cmH2O are randomly applied and gas exchange is measured. Both changes in oxygenation (PaO2) and in carbon dioxide (PaCO2) are evaluated. An increase in oxygenation likely reflects the amount of aerated tissue present at end expiration, or on the other hand, the amount of collapsed nonaerated tissue which has been maintained open at end expiration.

Ventilate with a noninjurious tidal volume

The tidal volume should be adjusted to maintain a transpulmonary pressure of 25–30 cm H2O.

Use the prone position

The prone position may induce lung recruitment, reduce the harmful effects of mechanical ventilation, and ameliorate gas exchange. The prone position should be used with caution in drowning patients with increased intracranial pressure because the prone position could further increase intracranial pressure by impairing venous return.

Adjuvant therapy

Different methods such as surfactant replacement, high-frequency ventilation or nitric oxide can be applied, although the definitive role of these therapies is still unclear.


  Conclusion Top


ARDS in nonfatal drowning may develop in up to 40% of the patients and part of these victims may need invasive mechanical ventilation. The outcome depends on the level of arterial hypoxemia and secondary complications. The outcome in drowning victims is better compared to ARDS of other etiologies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

I hereby authenticate that the above case report is published neither online nor in any other academic platforms and ascertain that this article is not plagiarized in any form. I request the esteemed editor to process the article for publication in your prestigious journal. I assure you that I will long associate with the journal in the future to come in terms of contribution with original article.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tyler MD, Richards DB, Reske-Nielsen C, Saghafi O, Morse EA, Carey R, et al. The epidemiology of drowning in low and middle-income countries: A systematic review. BMC Public Health 2017;17:413.  Back to cited text no. 1
    
2.
Ruggeri P, Calcaterra S, Bottari A, Girbino G, Fodale V. Successful management of acute respiratory failure with noninvasive mechanical ventilation after drowning, in an epileptic-patient. Respir Med Case Rep 2016;17:90-2.  Back to cited text no. 2
    
3.
Michelet P, Bouzana F, Charmensat O, Tiger F, Durand-Gasselin J, Hraiech S, et al. Acute respiratory failure after drowning: A retrospective multicenter survey. Eur J Emerg Med 2017;24:295-300.  Back to cited text no. 3
    
4.
Michelet P, Dusart M, Boiron L, Marmin J, Mokni T, Loundou A, et al. Drowning in fresh or salt water: Respective influence on respiratory function in a matched cohort study. Eur J Emerg Med 2019;26:340-4.  Back to cited text no. 4
    
5.
Lee KH. A retrospective study of near-drowning victims admitted to the intensive care unit. Ann Acad Med Singap 1998;27:344-6.  Back to cited text no. 5
    
6.
Szpilman D, Bierens J, Handley A, Orlowski J. Current concepts drowning. N Engl J Med 2012;366:2102-10.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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