Barotrauma (WARNING: contains references to intubation/ventilation)

I know what it is in relation to diving. Trauma from different pressures building up, divers usually get in ears. I am guessing it relates to using high pressures to ventilate but no doubt a Dr will be along shortly to explain it properly.

Hi Dave,

Barotrauma is damage to tissue - in relation to intubation, lung tissue - due to high pressures.

When an asthmatic has an attack and is intubated and ventilated, their airways are often very tight due to the underlying bronchospasm. This means that quite high pressures of air or oxygen are needed to be able to ventilate the lungs effectively. One of the potential complications of this is barotrauma. Rupture of the lung tissue allows air to escape from the alveoli (the air sacs at the ends of the bronchi in the lungs) and to surround the lung tissue. This can range from a subtle effect, with just a small amount of air around the alveoli in the interstitial tissue, to a life threatening pneumothorax, when air collects in the space between the lungs and the chest wall, threatening the function of the heart and lungs.

Barotrauma is usually suspected when there is a worsening of cardiac or respiratory status in the patient who is ventilated. They may become harder to ventilate or their sats or other observations may deteriorate. It is confirmed by clinical examination and by the presence of air in the wrong places on a chest X ray or occasionally a CT scan.

It may not require treatment if it is only minor, but if there is any amount of air present on X ray between the lungs and chest wall a chest drain is usually put in, which is a tube which goes through a small incision between the ribs on the chest wall and into the cavity between the lung and chest wall. The other end of the tube is put into a water seal so that the excess air can escape. This usually sorts the problem out and the lungs can then mend as the bronchospasm resolves and the pressures needed become lower.

Barotrauma is less of a problem these days, as ventilators are more sophisicated and better able to ventilate a patient without using excessive pressures, and also due to a practice called 'permissive hypercapnia', where the patient's CO2 levels are allowed to run higher than would be usual to avoid having to use dangerously high pressures. These advances in Intensive Care medicine have meant that, certainly in asthma, barotrauma is much more rarely seen. It is still seen more frequently in patients who are ventilated for other conditions such as Acute Respiratory Distress Syndrome (ARDS), where much higher pressures are needed.

'Normal' lungs which are not experiencing bronchospasm typically require pressures of perhaps 12 - 20 mmH2O to ventilate them; asthmatics having an acute attack might require pressures of 20 - 30 mmH2O. Barotrauma is a risk in any ventilation but is considered a much greater risk at pressures of over 35 mmH20. Patients with ARDS, for example, may require pressures of greater than 40 mmH20 for some time in order to effectively ventilate them.

If an asthmatic or anyone else being ventilated suffers from barotrauma, certainly if it is in the form of a significant pneumothorax, this does make the ventilation more risky and difficult to recover from. However, the vast majority of people do go on to make a full recovery from the experience.

The word barotrauma is also occasionally used to describe the long term, chronic damage that being ventilated at very high pressures (again, greater than 35 mmH20, unusual for asthmatics) may cause. This can include changes similar to emphysema, bronchiectasis or fibrosis. Again, this is far more common after things like ARDS than after ventilation for asthma. These changes can be thought of as a form of barotrauma, but the word is more commonly used to describe the situation I've detailed above.

Hope this helps, please do ask if there is anything more specific you want to know.

Take care

Em H

Thank you for your acknowledgment made in response to my question i think i understand it better. But not in relation to current situation. Can an exacerbation of two lung conditions that caused the ventilation in the first place, that has helped pneumonia to develop and problems with maintaining ventilation problems with blood gases,and other things after 6 days have contributed to this Barotrauma that is being thrown around as an explanation to these and other problems being experienced. Also sorry to ask but how serious is this will it improve and also why if ITU is so advanced has this occurred i am sorry if you feel this is all inappropriate to be asking these questions here but as i am not directly involved (as whilst on holiday my sisterinlaw became ill so is still there) i am getting second hand information from my brother every now and than and am extremely worried and here seemed like the best place to ask in the present circumstances. So i so hope i am not upsetting anyone by posting here.

Many thanks guys for your help Dave

Hi Dave,

I'm so very sorry to hear that Jaycie is so unwell again, it must be an incredibly anxious time for you and all the family. You are all in my thoughts and prayers. If there is anything I can do, please don't hesitate to ask.

It's difficult to answer your question without being there and knowing more about the exact clinical situation. Pneumonia is a recognised complication of ventilation and may itself predispose to the development of barotrauma by making the lungs stiffer and more difficult to ventilate, meaning that higher pressures are needed. Pneumonia can also predispose to the development of Acute Lung Injury and ARDS, which are in themselves risk factors for barotrauma. It sounds like there are many different factors interacting with the result that this intubation has become complicated.

As I said, Intensive Care and ventilation have improved enormously over the years, and such complications are a lot less frequent than they used to be. Most people on here who are unfortunately ventilated from time to time will never experience such complications. Unfortunately, though, ventilation is still an inherently risky thing to do to someone (which is why it's only done as a last resort) and these things do occasionally happen.

This is a serious situation, there's no point me trying to tell you that it isn't. In being in Intensive Care, though, Jaycie is in the best possible place to be looked after as well as possible. She's a strong person, she's got through similar things before, and so we will all just have to hope and pray that things go well.

Last year I went through a similar thing, with a prolonged intubation, pneumonia, and then the development of ARDS and other complications. It's been a long road, but I lived to tell the tale, and I am at last beginning to get back to some semblance of normal life. It is possible - please do hold onto that hope.

Thinking of you, take care of yourself and the family

Em H

Dear Emh

Thank you once again for your tremendous reply. Also thanks for the thoughts i shall pass on your good wishes to her family as i am sure it will help them knowing people are thinking of her.. It is very hard at the moment as i am sure you can imagine as this time last year we had been in a similar position with my daughter.

for a sister in law she is so generous and trust worthy without her support this past year i think i would not be as strong as i am today. Jaycie is a very strong lady and has a huge heart sometimes putting well mostly, others before her. I am sure this will be another set back she will fight her way through and win. Her boys are coping admirably and have been back to school this week her sister has come to care for them and they are being spoil t rotten.

I will most properly get in to a little trouble for asking these questions about her situation . but there is no one else to communicate this with that understands the place i am coming from. Yes i am scared and it is bringing far to much past back to the forefront of my thoughts and i do apologies if i have unduly upset people by posting about this situation here but i am sure if people don’t like it, it will be removed,and i will fully understand why.

I can understand why my daughter posted on here and loved to write to people even though when she first started i did not like the idea but seeing the true friendships and advice and the true comfort from this board she gained. I would like to have this opportunity to express my full gratitude to all those that knew and helped my daughter and myself and the people behind the scenes that keep it safe for the youngsters to have the support, advice and friendships they need to help them with day to day life living with different degrees of asthma.

God bless you all

Dave

Dave, I can only imagine how difficult things must be at the moment, with what you've been through with Hollyanna and what you are going through with Jaycie. I am sure it must bring back so many bad memories for you and for the rest of the family. I do hope things are beginning to improve now.

Please do not worry about upsetting people on the board with your posts; naturally we are all worried and upset about Jaycie, but I don't think that you've overstepped the line with what you have posted at all. You've not been graphic or gone into details. I have put a warning on the thread, so that if people don't want to read about ventilation, they don't have to, but I don't think at the moment that there is any question of editing or removing your posts.

Lots of thoughts and prayers to you, Jaycie, her boys and all the rest of the family.

Take care

Em H