Recombinant human growth hormone for reconditioning of respiratory muscle after lung volume reduction surgery.
OBJECTIVE
To investigate the effects of recombinant human growth hormone (rHGH) as a "rescue treatment" in an end-stage chronic obstructive pulmonary disease patient after prolonged weaning failure.


METHODS
Descriptive case report.


METHODS
Fifteen-bed intensive care unit in a university hospital.


METHODS
A 62-year-old man with end-stage chronic obstructive pulmonary disease and pulmonary emphysema after lung reduction surgery and prolonged weaning failure after long-term mechanical ventilation.


METHODS
After 42 days of unsuccessful weaning from the respirator, rHGH (27 IU/day, 0.3 IU/kg body weight/day) was administered for 20 days through a subcutaneous injection in addition to standard intensive care.


RESULTS
In addition to daily routine laboratory studies, the visceral proteins prealbumin, retinol-binding protein, and transferrin, and nitrogen balance were measured twice a week, as were the thyroid hormones triiodothyronine, thyroxine, and thyroid-stimulating hormone, plasma insulin levels, and the insulin-like growth factor (IGF)-1 binding proteins IGF-BP1 and IGF-BP3. IGF-1 was measured from day 1 to day 4 of rHGH administration. Nutritional support was guided by indirect calorimetry. Additionally, weaning variables such as peak expiratory flow rate and expiratory tidal volume were measured noninvasively. T-piece weaning trials were carried out daily until respiratory muscle fatigue occurred. IGF-1 increased in response to rHGH stimulation, from 103 to 230 microg/mL, within 4 days. The carrier protein IGF-BP3 increased from 126 to 283 mg/L at the end of the study period, and the inhibiting IGF-BP1 decreased initially from 19 to 14 mg/L and then increased until the end of the study to 31 mg/L. Nitrogen balance increased initially from 4.6 to 13.6 g/24 hrs and thereafter decreased until the end of rHGH treatment to 8.3 g/24 hrs. Resting energy expenditure increased from 1800 to 2300 kcal/24 hrs. Peak expiratory flow rate increased from 0.69 to 0.88 L/sec. The expiratory tidal volume showed a slight increase during the study period during the daily decrease of pressure support on the ventilator setting. Respiratory muscular strength increased beginning 10 days after rHGH therapy was started. From this point, T-piece weaning trials could be prolonged almost daily. The patient was extubated successfully on postoperative day 75.


CONCLUSIONS
This case report shows that after a prolonged catabolic state and long-term mechanical ventilation, administration of rHGH not only enhances the response of protein metabolism but improves respiratory muscular strength. Therefore, it may reduce the duration of mechanical ventilation in selected patients.
Felbinger
T W
TW
Clinic for Anesthesiology, Ludwig-Maximilians-Universität, Klinikum Grosshadern, Munich, Germany. felbinger@lrz.uni-muenchem.de
Suchner
U
U
Goetz
A E
AE
Briegel
J
J
Peter
K
K
D004734:Energy Metabolism; D019382:Human Growth Hormone / Q000627:therapeutic use*; D006801:Humans; D007334:Insulin-Like Growth Factor I / Q000187:drug effects / Q000378:metabolism; D008173:Lung Diseases, Obstructive / Q000378:metabolism / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009584:Nitrogen / Q000378:metabolism; D010366:Peak Expiratory Flow Rate; D011013:Pneumonectomy / Q000534:rehabilitation*; D011182:Postoperative Care / Q000379:methods*; D012132:Respiratory Muscles / Q000187:drug effects* / Q000503:physiopathology; D013990:Tidal Volume; D013997:Time Factors; D015300:Ventilator Weaning
D019382:Human Growth Hormone; D007334:Insulin-Like Growth Factor I; D009584:Nitrogen