To discuss the relationship between weaning from TPPV and physiotherapy and nutritional management in a patient with suspected MSA and nutritional disorders.
A woman in her 60s with suspected MSA had low body mass index (BMI), dyspnea, gait disturbance, constipation, and orthostatic hypotension for several years without a definitive diagnosis. One year before, she had undergone TPPV for respiratory failure and was successfully weaned off. However, TPPV was required again because of aspiration pneumonia. On admission, her BMI was 13.0 kg/m², indicating severe malnourishment according to the Global Leadership Initiative on Malnutrition criteria, and she was administered 1550 kcal/day. The ventilator settings were positive end-expiratory pressure, 5 cmH2O; pressure support ventilation, 7 cmH2O; FiO2, 0.35; and SpO2, 97% in synchronized intermittent mandatory ventilation mode. The rapid shallow breathing index (RSBI) was 120 at rest (standard, 105). Blood data showed C-reactive protein, 12.23 mg/dL ; albumin, 2.7 g/dL; and hemoglobin, 10.8 g/dL, indicating invasive catabolic phase due to undernutrition and pneumonia.
Functional assessment revealed body weight, 34.2 kg; grip strength, 12 kgf; calf circumference, 22 cm; and mild left dominant rigidity. Weaning from TPPV was considered difficult owing to generalized muscle weakness, malnutrition, and associated decreased ventilation efficiency and increased respiratory workload. To avoid skeletal muscle damage, physiotherapy comprised low-intensity exercises, such as range-of-motion training, manual resistance, and repositioning.
On day 23, inflammatory markers improved, and she was weaned off the bed; resting RSBI was 45. Initially, sitting RSBI was 150. The skeletal muscle index was 4.0. On day 37, she started standing, and sitting RSBI was 110. On day 45, her weight decreased to 30.3 kg; therefore, nutritional requirements were adjusted to 1880 kcal/day. Blood data showed C-reactive protein, 0.25 mg/dL; albumin, 4.0 g/dL; and hemoglobin, 11.5 g/dL. The ventilator settings were synchronized intermittent mandatory ventilation mode, positive end-expiratory pressure, 5 cmH2O; pressure support ventilation, 5 cmH2O; FiO2, 0.25; SpO2 99%; and sitting RSBI, 80.
Weaning was considered possible and started on day 48. On day 51, ventilator support was removed during the day and only continuous positive airway pressure at night. The patient was discharged on day 60 and continued physiotherapy and nutritional support at home. Activities of daily living improved.
The respiratory function deteriorated because of disease-related symptoms, aging, disuse, malnutrition, and low BMI. During the increased catabolism after aspiration pneumonia, we adjusted the physiotherapy while considering nutritional status, which improved respiratory function and general condition, allowing weaning from TPPV.
Ventilator weaning should be considered in similar cases.
weaning from ventilation
malnutrition
