Combined spinal-propofol anesthesia with noninvasive positive-pressure ventilation

Twenty-three adult patients undergoing repair of inguinal hernia under spinal anesthesia received propofol infusion for sedation with the assist of noninvasive positive-pressure ventilation (NPPV). Circulatory and respiratory parameters, such as percutaneous oxygen saturation, transcutaneous carbon dioxide tension, respiratory rate, tidal volume, blood pressure, and heart rate, were maintained within physiological ranges during the anesthesia. There were no adverse effects. These findings suggest that the application of NPPV in patients receiving propofol infusion for sedation is clinically practicable during anesthesia.     

Full face mask for noninvasive positive-pressure ventilation in patients with acute respiratory failure

BACKGROUND: Noninvasive positive-pressure ventilation (NPPV) is commonly used to improve ventilation and oxygenation in patients with acute respiratory failure (ARF). Mask leak and intolerance due to facial discomfort or claustrophobia often occur with NPPV and are frequently cited reasons for treatment failure. METHODS: Retrospective review of patient records from a tertiary-care referral hospital. Results: We report the effectiveness of a full face mask in the application of NPPV for 10 nonambulatory patients (mean [SD], 61 [9] years) who had a combined total of 13 episodes of ARF. After these patients were unable to receive NPPV therapy via the more commonly available nasal or oronasal masks, care was provided using full face masks. Eight of 10 patients had hypercapnic respiratory failure; 2 patients, hypoxemic respiratory failure. All patients were placed on ventilation initially using a bi-level positive airway pressure device. Subsequently, patient ventilation was achieved using a Puritan Bennett 7200a ventilator for on-line respiratory monitoring. The mean (SD) duration of treatment with NPPV was 9.7 (2.7) hours per day for 3.0 (1.6) days. Following NPPV via full face mask, the patients' Paco(2) decreased (65 [20] vs 82 [27] mm Hg, P=.09) and pH increased significantly (7.36 [0.07] vs 7.26 [0.07], P<.05) in less than 2 hours. Moreover, the patients demonstrated decreased respiratory rate (18 [7] vs 32 [8] breaths/min, P<.01), heart rate (106 [13] vs 124 [16] beats/min, P=.008), and Acute Physiology and Chronic Health Evaluation II scores (12 [3] vs 17 [4], P<.005) after NPPV via full face mask. These cardiorespiratory alterations occurred as early as 1 hour after NPPV initiation and were maintained throughout treatment. Two patients required endotracheal intubation because of copious purulent secretions. CONCLUSION: For individuals with hypercapnic respiratory failure who cannot tolerate NPPV using nasal or oronasal masks, use of full face masks may improve outcomes, allowing physicians to avoid ordering endotracheal intubation and mechanical ventilation.     

Fiberoptic bronchoscopy during noninvasive positive-pressure ventilation in patients with chronic obstructive lung disease with hypoxemia and hypercapnia

OBJECTIVES: To assess the feasibility and safety of non invasive positive-pressure ventilation (NIPPV) via a face mask to performing fiberoptic bronchoscopy (FOB) in patients with COPD contraindicating FOB in spontaneous ventilation. STUDY DESIGN: Clinical, prospective, open, non comparative trial of feasibility. PATIENTS: Ten consecutive COPD patients (71 +/- 5 year-old, PaO2 = 53 +/- 13 mmHg and PaCO2 = 67 +/- 11 mmHg), without any sign of acute respiratory failure, admitted to the intensive care unit for pneumonia requiring a bronchoalveolar lavage (BAL). Including were: PaO2 < 70 mmHg despite nasal O2 delivered at 3 L.min-1, PaCO2 > 50 mmHg, improvement of SpO2 with NIPPV before FOB. METHODS: Topical anaesthesia of the nose and pharynx was obtained with a 5% lidocaine spray. NIPPV was administered using a ventilatory support system Evita 4 (Dr?ger) applied through a full facial mask secured to the patient with elastic straps. Patients were first allowed to acclimate for 5 min with NIPPV (IPAP = 16 cmH2O, EPAP = 0 and trigger of 0.3 cm H2O while a FIO2 kept at 0.7). A T-adapter Medisize (Péters) was attached to the facial mask. The tip of the FOB was inserted through the nose. Topical anaesthesia of the vocal cords was obtained with 1% lidocaine solution (3 mL). The FOB was inserted into the trachea up to a bronchial sub-segment. BAL was performed by instillation of 100 mL of saline solution. After FOB, the NIPPV was maintained for 5 min. Heart rate, SpO2 were measured continuously and arterial pressure at 2 min intervals. Arterial blood gas values were obtained just prior NIPPV and after 15 min and 60 min NIPPV disconnection. RESULTS: FOB duration was 11 +/- 4 min. SpO2 significantly improved during FOB (from de 91 +/- 4.7% to 97% +/- 1.7) without decrease of oxygen saturation lower than 90%. There were no changes in PaCO2 and PaO2 during the hour following the end of procedure. FOB under NIPPV was performed in all patients without complications and was very well tolerated in eight patients. After NPPV disconnecting, one patient required again NIPPV for 15 min. No patient required endotracheal intubation within 24 hours. All patients survived. CONCLUSION: Application of NIPPV during FOB is a safe technic for maintaining adequate gas exchange in hypoxaemic and hypercapnic COPD patients not in acute respiratory failure. After the end of the procedure a close surveillance in the intensive care unit is essential.     

Postoperative atelectasis after one-lung ventilation with the Univent tube in a child

This case describes a postoperative complication after single-lung ventilation in a 10-year-old patient scheduled for scoliosis repair. This patient underwent an anterior thoracoscopic excision of several vertebral discs followed by a posterior double-rod fixation of her spine. The postoperative course was complicated by complete atelectasis of the patient's right lung for 5 days. Methods of single-lung ventilation, advantages and disadvantages of the Univent tube versus the double-lumen tube, and the possible mechanisms leading to postoperative atelectasis in this child are discussed.     

Treatment of severe cardiogenic pulmonary edema with continuous positive-pressure ventilation using a cuffed cannula Copa]

We report the use of a cuffed oropharyngeal airway (Copa), in a patient with an acute respiratory failure from a cardiogenic pulmonary oedema, for continuous positive pressure ventilation. Considering the ease of use and the lack of laryngeal stimulation, this device can be considered for mechanical ventilation in selected cases with acute cardiac failure. There are two contra-indications: prolonged mechanical ventilation, because of the lack of airway protection from gastro-oesophageal reflux, and normal consciousness, as the patient cannot swallow. This device can be considered when starting intensive therapy including mechanical ventilation in patients with acute respiratory failure of foreseen short duration.     

Airway obstruction during general anaesthesia in a child with congenital tracheomalacia

Fibreoptic bronchoscopy is often used to diagnose tracheomalacia under local anaesthesia. However, in children, general anaesthesia may be required due to difficulty in obtaining co-operation. A 1-yr-old girl with a suspected congenital tracheomalacia was scheduled for diagnostic fibreoptic bronchoscopy. During induction of anaesthesia by inhalation of increasing concentration of sevoflurane, spontaneous breathing became irregular and a partial airway obstruction occurred. Because vecuronium relieved the airway obstruction, the airway was managed using a laryngeal mask. No further airway obstruction occurred during fibrescopy under controlled ventilation, but when spontaneous breathing resumed, marked airway obstruction occurred. The trachea was intubated immediately. Caution is required to manage the airway without tracheal intubation during general anaesthesia in the patient with tracheomalacia.     

Haemodynamic changes during positive-pressure ventilation in children

BACKGROUND: Positive-pressure ventilation may alter cardiac function. Our objective was to determine with the use of impedance cardiography (ICG) whether altering airway pressure modifies the central haemodynamics in mechanically ventilated children with no pulmonary pathology. Central venous saturation (S(cv)O(2)) was measured as an indicator of tissue perfusion. METHODS: Twelve children between 7 and 65 months of age, requiring mechanical ventilation as a consequence of a non-pulmonary disease, were enrolled in the study. All patients had a central venous line as a part of their routine management. Using pressure controlled ventilation (PCV) the baseline PEEP value of 5 cmH(2)O (P(b5)) was increased to 10 cmH(2)O (P(i10)) and then to 15 cmH(2)O (P(i15)). After P(i15), PEEP was decreased to 10 (P(d10)) and then to 5 cmH(2)O (P(d5)). Each time period lasted 5 min heart rate (HR), mean arterial blood pressure (MABP), central venous pressure (CVP), end-tidal carbon dioxide (ETCO(2)), mean airway pressure (P(aw)), stroke volume index (SVI), cardiac index (CI) and central venous oxygen saturation (S(cv)O(2)) were recorded at the end of the five periods. RESULTS: The values of CI did not change when 10 and 15 cmH(2)O of PEEP were applied. Elevation of PEEP and thus P(aw) caused slight but not significant reductions in SVI and S(cv)O(2) as compared to the baseline (T(b5)). After reducing PEEP in T(d5) we found statistically significant elevations of SVI and CI, as compared to T(i15) heart rate, ETCO(2) and MABP remained unchanged. CONCLUSION: We did not find significant haemodynamic changes following PEEP elevation in ventilated children, as measured using impedance cardiography. Reducing the value of PEEP to 5 cmH(2)O resulted in statistically significant SVI elevations. The values of S(cv)O(2) remained unaffected.     

Vascular sling with tracheomalacia: surgical management

Surgical repair of pulmonary artery sling without concomitant correction of associated tracheal abnormalities has yielded poor results in the past. We combined vascular sling repair done during cardiopulmonary bypass through a median sternotomy incision with tracheopexy for severe associated tracheomalacia in 2 infants. Neither experienced substantial postoperative respiratory difficulties and both had patent vascular anastomoses at 1 year after repair, thus supporting this approach when this combination of lesions is present.     

The role of aortopexy in severe tracheomalacia

Purpose

Aortopexy is the accepted operative treatment for severe and localized tracheomalacia (TM). The standard surgical approach involves a left anterior thoracotomy, often under bronchoscopic control. We report the results of aortopexy in 28 children with severe and localized TM; 12 had a left lateral muscle-sparing approach and one had a thoracoscopic aortopexy.

Methods

Retrospective review of patient notes was performed to note the indications, investigation findings, and postoperative course after aortopexy.

Results

The median age at aortopexy was 5 months. The indications included acute life-threatening events in 22, failure to extubate in 5, and recurrent pneumonia in 1. Fifteen had associated esophageal atresia and 13 had primary TM. Symptoms of TM were abolished in 26 of the 28 patients after aortopexy.

Conclusions

Aortopexy is a safe and reliable procedure to treat localized intrathoracic TM presenting with acute life-threatening events. It is important to exclude associated problems such as vascular rings and to ensure that the tracheomalacic portion is segmental and does not significantly involve the main bronchi. The lateral muscle-sparing thoracotomy provides good access and is more cosmetic than the standard anterior approach. We would attempt the thoracoscopic approach in older infants and children.     

Thoracoscopic aortopericardiosternopexy for severe tracheomalacia in toddlers

Background/Purpose: Aortosternopexy from a left anterolateral thoracotomy is the procedure of choice in severe tracheomalacia. The authors report an alternative technique of modified thoracoscopic aortopericardiosternopexy. Methods: Thoracoscopy under mild CO₂ insufflation (insufflation pressures 4 to 6 mm Hg) provides excellent access without selective intubation. The importance of visualizing the phrenic nerve, mobilization of the thymus without disrupting its vascular supply, and intraoperative bronchoscopy is stressed. The technique of passing the needle through the sternum and back is shown. In long segment tracheomalacia, not only the ascending aorta, but also the innominate artery and base of the pericardium are fixed to the sternum, and the effect is monitored by intraoperative bronchoscopy. Results: This technique was dramatically successful in a 4-year-old boy with long segment tracheomalacia and as a redo procedure in a 2-year-old girl after failed open aortopexy. Conclusion: Thoracoscopic aortopexy seems to be as effective as open aortopexy. J Pediatr Surg 37:1476-1478.