HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chihara, K. Articles by Hirata, T. Search for Related Content PubMed PubMed Citation Articles by Chihara, K. Articles by Hirata, T.

J Thorac Cardiovasc Surg 1996;111:1281-1283
© 1996 Mosby, Inc.

BRIEF COMMUNICATIONS

VENTILATORY SUPPORT WITH A CUIRASS RESPIRATOR AFTER RESECTION OF BULLOUS EMPHYSEMA: REPORT OF A CASE

Shizuoka, Japan

Received for publication Oct. 3, 1995 Accepted for publication Oct. 10, 1995. Positive-pressure ventilation (PPV) after operation for emphysema is undesirable because it often yields a persistent air leak. We report a case in which hypercarbia after bullectomy was treated successfully by negative-pressure ventilation (NPV) with a cuirass respirator (Sumitomo Bakelite, Japan). ¹

Case report

In June 1995, an 82-year-old man with emphysema was transferred to our hospital for severe dyspnea and unconsciousness. Arterial blood gas measurements showed an oxygen tension of 74 mm Hg, a carbon dioxide tension (PcO₂) of 141 mm Hg, and the chest radiograph revealed left pneumothorax. An endotracheal tube and a chest tube were immediately inserted. The patient was extubated for 1 day after PPV. The computed tomographic scan revealed giant bullae in the left lower lobe (Fig. 1). Because air leakage had been intractable for a month, we performed a left thoracotomy. Air leakage from the bullae was 40% of inspired tidal volume. A 75 mm linear stapler covered by a sheath-shape fabric made from polyglycolic acid (Neoveil; Gunze, Japan) was used for bullectomy three times. Small air leaks at the stapling junctions needed additional sutures and fibrin glue. After the absence of air leaks was confirmed, the chest was closed. Although reversal of muscle relaxation was accomplished, tidal volume was less than 100 ml. Intermittent manual ventilation failed to decrease PCO₂. Air leakage began in the meantime. We transferred the patient to the recovery room and started NPV with a cuirass respirator. ¹ An inspiratory peak pressure of -30 cm H₂O at a rate of 20 breaths/min by the respirator had been applied for 4 hours. Tidal volume increased from 113 to 185 ml. PcO₂ gradually decreased, and the patient became alert. He breathed spontaneously after NPV and was extubated thereafter (Fig. 2). The degree of air leakage did not change during NPV. The patient had been showing a slow but steady recovery; however, right pneumothorax suddenly occurred 3 weeks after operation. Because air leakage was again persistent, right thoracotomy was obligatory 3 weeks later. An air leak from a small bulla of the apex of the lower lobe was closed tightly. Because the patient had been feeling discomfort and vomiting after meals after operation, intravenous hyperalimentation was begun. Although the patient, once more made a slow recovery, he reported general malaise and productive coughs a week later, and Pco₂ then was 86 mm Hg. We began PPV, but the patient died of heart failure 2 days later.

View larger version (87K): [in this window] [in a new window]   Fig. 1. Chest computed tomographic scan 2 weeks after admission shows giant bullae in the emphysematous lower left lobe.

View larger version (28K): [in this window] [in a new window]   Fig. 2. Arterial blood gas measurements and respiratory rate before, during, and after NPV. Po2, Oxygen tension; Fio2, inspired oxygen fraction.

The most troublesome complication after operation for emphysema is prolonged air leakage. Cooper and colleagues ² pointed out two important points in avoiding this complication. One is making every attempt to completely eliminate air leaks during operation. The other is avoiding excessive stress on the lung surface after operation. ² To accomplish the latter point, recovery of spontaneous breathing as soon as possible ² and low-pressure suction of the chest tubes after operation are critical. ^2,3 Some ventilatory support is necessary, however, when a patient continues to have hypoventilation after operation. Pressure-controlled ventilation rather than volume-controlled ventilation has been recommended for such patients because it can deliver high inspired gas flows in the presence of airway leaks. ³ Although NPV is generally less effective than PPV, ¹ it places less stress on the airway. Even if a peak inspiratory pressure inside the cuirass respirator is highly negative, a fraction of the pressure is transmitted to pleural pressure in patients with chronic obstructive pulmonary disease during cuirass ventilation. ⁴ Marino and Pitchumoni ⁴ showed that esophageal pressure decreased from -5.4 cm H₂O during spontaneous breathing to -7.3 cm H₂O during inspiratory cycle of NPV while an inspiratory peak pressure of -40 cm H₂O inside the cuirass worked on the chest. In contrast, during PPV a high positive peak pressure is transmitted to the airway and lung. NPV may therefore be less likely than PPV to induce barotrauma in patients with fragile stapling lines of the lung. Indeed, the decrease in PcO₂ in our patient may have been rather slow compared with PPV; however, NPV successfully led him to stable spontaneous breathing without increasing air leakage. Although our patient died, we believe that NPV with the cuirass respirator could be an appropriate ventilatory support for the patient with hypercarbia after operation for emphysema when the lung is adequately inflated.

Footnotes

From the Departments of Thoracic Surgery^a and Respirology,^b Shizuoka City Hospital, Shizuoka, Japan.

J THORAC CARDIOVASC SURG 1996;111:1281-3

References

1. Chihara K, Kawarasaki S, Hitomi S, Shimizu Y. A new cuirass respirator synchronizing with spontaneous respiration and its clinical application [Abstract]. Chest 1988;94:44S.
   
2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumenectomy (volume reduction) for chronic obstructive pulmonary disease. J THORAC CARDIOVASC SURG1995;109:106-19.
   
3. Barker S, Clarke C, Trivedi N, Hyatt J, Fynes M, Roessler P. Anesthesia for thoracoscopic laser ablation of bullous emphysema. Anesthesiology 1993;78:44-50.[Medline]
   
4. Marino WD, Pitchumoni CS. Reversal of negative pressure ventilation–induced lower esophageal sphincter dysfunction with metoclopramide. Am J Gastroenterol 1992;87:190-4.[Medline]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Chihara, K. Articles by Hirata, T. Search for Related Content PubMed PubMed Citation Articles by Chihara, K. Articles by Hirata, T.