Perioperative management of a patient with deventilation syndrome

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ObesityResearch&ClinicalPractice14(2020)103–105

ContentslistsavailableatScienceDirect

Obesity

Research

&

Clinical

Practice

j o ur na l h o me p a g e :w w w . e l s e v i e r . c o m / l o c a t e / o r c p

Case

Report

Perioperative

management

of

a

patient

with

deventilation

syndrome

Cigdem

Akyol

Beyoglu

∗

,

Guniz

Meyanci

Koksal

IstanbulUniversity-Cerrahpasa,CerrahpasaSchoolofMedicine,DepartmentofAnesthesiologyandReanimation,Istanbul,Turkey

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received29May2019

Receivedinrevisedform24October2019 Accepted6January2020

Introduction

Nowadays,manypatientswithchronicobstructivepulmonary disease(COPD)andobstructivesleepapneasyndrome(OSAS) con-tinuetheirliveswithhomeventilatorsandnoninvasivemechanical ventilation(NIV)treatment[1].Thedifficultyofusinghome ven-tilators is that ventilation cannot be observed and monitored adequatelybyaphysician.InOSASpatientsundergoingNIV treat-ment,justaftercessationofNIVtreatmentinthemorning,dyspnea, headache,anddizziness mayoccur. Thisconditionisdefinedas deventilationsyndrome(DS)[2].Inaddition,inpatientswithCOPD andOSAS,progressivehyperinflationduringtheuseofNIV, hyper-carbia,andhypoventilationatnightcauserespiratorydistressin themorningwhichisalsodefinedasDS[2].

InOSAPatients,NIVtreatmentprovidesapositivepressureto theairwaysandpreventspharyngealmusclecollapse.Patients suf-feringDScannotperformdailyactivitiesforatleast30min.After then,thepatientawakensandimprovedmuscletonegetsoverthe effectsofimproperNIVapplication.Patientventilatorasynchrony isthoughttobethemostcausativefactorofDS[2–4].

ItwasreportedthatnearlyonethirdofCOPDpatientsunder homeventilationtreatmentcomplainedof“deventilationdyspnea” [3].Inaddition,inapreviousreport,itwasstatedthat“morning dyspnea”isquitecommoninpatientsreceivinghomeNIVduring thenight[5].Sincebariatricsurgeryisthemostcommon opera-tionformorbidlyobesepatients,webelievethatthemostcommon groupof patientswhowill beaffectedby DSare patientswho willundergobariatricsurgerywithNIVtreatmentathome.This syndromehasbeenintheattentionofpulmonarycareclinicians and anesthesiologistssince it wasrealizedthatpatient ventila-torasynchronyanddeventilationdyspneaoccurmoreoftenthan previouslysuggested[6].

∗ Correspondingauthor.

E-mailaddress:cigdem.akyol@istanbul.edu.tr(C.A.Beyoglu).

Wepresentacaseofunilaterallaparoscopicadrenalectomywith DSusingahomeventilator.Inourcountry,thenumberofpatients usingNIVathomeisgrowingandanesthesiaphysiciansaregoingto encountersuchpatientsmoreofteninthefuture.Wewanttodraw attentiontothisissueduringtheperioperativeperiod,especially inpreoperativepatientevaluationandthepostoperativeperiod.

Case

Ourcaseisa37-year-oldmalepatientwithAmericanSocietyof Anesthesiology(ASA)PhysicalStatusClassIIandabodymassindex (BMI)of40kg/m2_with_unilateral_inactive_adrenal_hyperplasia.

Laparoscopicadrenalectomywasplannedforthepatient,and hewashospitalized.ThepatientwasundergoingNIVtreatmentat homeforthreeyearswiththediagnosisofOSAS.TheNIVtreatment wasbeingappliedincontinuouspositiveairwaypressure(CPAP) modewithanoronasalmask.TheCPAPparameterswereinroom air(FiO2:0.21)inCPAPmodewith10cmH2Opressure.

Thepatientsufferedfromrespiratorydistress,headache, sweat-ing,andpersistenttirednesswhenhewokeupinthemorningafter cessationofNIVtreatment.Thesecomplaintscontinuedforabout 20minafterwakingup.Thepatienthadnootherchronicdisease anddidnottakeanymedications.Onphysicalexamination, bilat-eralrespiratorysoundswereequal,andrespiratorysoundsinthe basalareaweredecreased.Therewerenoadditionalpathological lungsounds.Therespiratoryfrequencywas14breaths/min,and therhythmicheartratewas83beats/min.Hehadnoperipheral edema.Peripheraloxygensaturation(SpO2)was92%inroomair. Therewerenoabnormalbiochemistry results.Therewere ﬁnd-ingsofhyperinﬂationonthechestX-ray.TheECGshowedsinus rhythmat85beats/min.Arterialbloodgasanalysisrevealedthe following:pH:7.39, PaO2:74.1mmHg,PaCO2:41.6mmHg,and HCO3:28mmol/L.Sincehehadrespiratorycomplaintswhenhe wokeupinthemorning,itwasdecidedtorepeatbloodgas anal-ysisjustbeforetheNIVwasterminatedthenextmorning.Inthe secondbloodgasanalysis,thefollowingresultswereobtainedjust https://doi.org/10.1016/j.orcp.2020.01.003

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104 C.A.Beyoglu,G.M.Koksal/ObesityResearch&ClinicalPractice14(2020)103–105 Table1

Perioperativevaluesofbloodgasanalysis,SPO2andHR.

PreoperativeIa _Preoperative_IIb _{Intraoperative} _{Postoperative}c

SPO2(%) 92 93 98 95 PH 7.39 7.32 7.36 7.39 PO2mmHg 74.1 76.7 110 78 PCO2mmHg 41.6 62.3 38 40.8 HCO3mmol/L 28 30 26 26 HRbeats/min 83 85 90 80

a_During_preoperative_{consultation.} b _In_the_morning_of_operation. c _{Postoperative}₆₀th_min.

Table2

Bloodgasanalysis,SPO2andHRaccordingtoCPAPpressures.

CPAPwith10cmH2O CPAPwith8cmH2O

SPO2(%) 92 95 PH 7.39 7.4 PO2mmHg 74.1 78 PCO2mmHg 41.6 48 HCO3mmol/L 28 26 HRbeats/min 85 80

beforeNIVterminationinthemorning:pH:7.32,PaO2:76.7mmHg, PaCO2:62.3mmHg,andHCO3:30mmol/L.

RoutineECGmonitoringshowedsinusrhythmat90beats/min, non-invasivebloodpressurewas140/80mmHg,andSpO2was93%. Preoxygenationwasperformedwiththreedeepbreathsand100% oxygenbeforeinductionofanesthesia.Forinductionofanesthesia, 2mg/kgpropofol(Propofol1%,FreseniusKabi,Germany),0.6mg/kg rocuronium (Muscuron 50mg/5ml, Koc¸ak Farma, Turkey), and 0.1mg/kg/minremifentanil(Ultiva5mg/ml,Abbott,USA)infusion wereused.Formaintenanceofanesthesia,remifentanilinfusion 0.05–0.2␮g/kg/min,sevoﬂurane(Sevorane,AbbVie,USA),and40% oxygen O2/air 2/2 mixture were used. Positive end-expiratory pressure(PEEP):8cmH2O,I/E½breathing frequencywassetto 12breaths/mininthepressurecontrolmodetomaintainETCO2 36–38mmHg.

Thepatientunderwentsurgeryinthelateraldecubitusposition. Nochangesinventilatorparameterswererequiredafter abdom-inal insufﬂation. Ph: 7.36, PaO2: 110mmHg, PaCO2: 38mmHg, andHCO3:26mmol/Lweretheresultsoftheintraoperative arte-rialblood gasanalysis.Duringtheentire operation,ETCO2was 36–38mmHg,SpO2was98%,andnoarterialbloodgassamplewas takenagainbecausetherewerenochanges.Sugammadex4mg/kg (becauseitwasacceptedasadeepblock)wasusedtoantagonize theneuromuscularblock.

Hewastakentotherecoveryunitwhere2ml/minoxygenwas administeredviafacemask.TheECGwas85beats/min,SpO2was 95%,andrespiratoryfrequencywas13breaths/minduring spon-taneousrespiration.Thevisualanalogscale(VAS)painscorewas foundtobe3.Therewerenocomplaintsofrespiratory distress intherecoveryunit. Arterialblood gasanalysiswasperformed atthe60th_min_{postoperatively}_and_revealed_the_following:_pH:

7.39,PaO2:78mmHg,PaCO2:40.8mmHg,andHCO3:26mmol/L. The change of blood gas analysis, SPO2 and HR are shown in Table1.WhentheAldretescorewasgreaterthan9andtheVAS painscorewas2,thepatientwastransportedtotheward.Inthe eveningofpostoperativeday0,thepatient’sCPAPwasdecreased to8cmH2Oand appliedwithanoronasalmask atnight.Inthe morning of the ﬁrst postoperative day,the morning dizziness, headache,andfatigueweredecreased.Thearterialbloodgasresults wereasfollows:pH:7.4,PaO2:78mmHg,PaCO2:48mmHg,and HCO3:26mmol/L.Thechangeofbloodgasanalysis,SPO2andHR areshown inTable2.The patient,whowasventilatedwiththe sameventilatorparametersonthesecondpostoperativeday,was

referredtothesleeplaboratoryforpolysomnographicexamination onthethirdday.

Discussion

Currently,itispossibletoencounterDSinpatientsunderhome ventilator treatmentwithOSASand COPD [2]. In patientswith DS,polysomnographicstudiesmustbeperformed,theunderlying causeshouldbeinvestigated,andasolutionmustbefound.Patients canperformtheirdailyactivitieswiththeapplicationofventilator therapyinappropriatemodesandpressures.

In some centers, the ventilator pressure settings are main-tained ata higherlevel than necessary tomaintainpatientsat the safe limit. These high pressures may cause hyperinflation insomepatients[7].Therewerehyperinflationfindings onthe chest X-rayof our patient. In ourcase, on themorning of the first postoperative day, when the patient no longer required theventilator,thearterialblood gassamplerevealed hypercar-bia,butthePaCO2leveldecreasedduringtheday.Althoughthe patient wasunder NIV treatment, he sufferedfrom respiratory distress, poor sleep quality, and fatigue symptoms during the day.

Theseproblemssuggestedafailureofsuccessfulnight ventila-tionwhichwascausingDS.Inrecentyears,thenumberofpatients monitoredbytheventilatorathomehasbeenincreasing,sowewill befacedwithsuchcasesmoreoften.

In the preanesthetic examination, we need to check which parametersthepatientisbeingventilatedwith.Iftheoperation isnot urgent,patientcompliancewiththeventilatorshouldbe investigatedbyrequestingapolysomnographicexamination.The patient-ventilatormismatchassociated withhyperinflationmay requireadjustmentofnewtriggerlevelsandpressurelevels[8]. Hyperinflationcancontributetopostoperativerespiratoryfailure byaffecting thediaphragmatic functionthrough various mech-anisms. This risk is highest in patients undergoing abdominal surgery[8].FactorsunderlyingDS,suchaspulmonaryemphysema, airtrapping,and hyperinflation,mayalter respiratory functions adversely,especiallyafterabdominalsurgery.Hyperinflation pre-vents optimal generation of negative intrathoracic pressure by affecting diaphragmatic function and contributes to postopera-tivepulmonarydysfunction[9–12].Itisclearthatmorbidlyobese patientswithOSAS under suboptimalNIV treatmentare prone topostoperativepulmonarycomplications.Changingtriggerand pressurelevelsmaysolveasignificantpartoftheproblemsdue toDSandhelpmaintainasaferpostoperativeperiod.Wedidnot postponetheplannedsurgeryinthiscase.

To avoid postoperative pulmonary complications under NIV treatment after abdominal surgery, we suggest adjusting the ventilator settingsand reversing theundesirable effects of NIV treatment.Todothis,weneedtoclearlypresenttheundesirable effectsofNIV.Adetaileddescriptionofmorningsymptoms, arte-rialbloodgasanalysis,andpolysomnographicstudies(ifrequired) shouldbestatedmeticulously.

Weusedshort-actinghypnoticandopioiddrugsinourcasewith DS.Wepreferrednonsteroidalanti-inflammatoryanalgesicsafter extubationandinthewardinordertoavoidthecentral respira-torydepressioneffectsofnarcoticdrugs.Inourliteraturesearch, wecouldnotfindascientificarticledescribingtheperioperative managementofDS.

AsaresultoftheincreasinguseofhomeNIV,wewillencounter patientswithDSmoreoften.Itshouldbekeptinmindthatitis dif-ﬁculttofollowuppatientsusinghomeventilator.Preparingthese patientsforoperationinthepreoperativeperiodandgettingthem underappropriateconditionswillbeappropriateforthesafetyof thepatient.

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C.A.Beyoglu,G.M.Koksal/ObesityResearch&ClinicalPractice14(2020)103–105 105

Conﬂictofinterest None.

Funding

Authorsdeclarenofundingforthereport. CRediTauthorshipcontributionstatement

CigdemAkyolBeyoglu:Conceptualization,Datacuration, For-mal analysis, Funding acquisition, Investigation, Methodology, Projectadministration,Resources,Software,Supervision, Valida-tion, Visualization, Writing - original draft,Writing - review & editing.GunizMeyanciKoksal:Conceptualization,Datacuration, Formalanalysis,Investigation,Methodology,Project administra-tion,Resources, Supervision,Validation, Visualization,Writing -originaldraft,Writing-review&editing.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in theonline version,at doi:https://doi.org/10.1016/j.orcp.2020.01. 003.

References

[1]Esquinas AM,UcarZZ,KirakliC.Deventilation syndromeinsevereCOPD patients duringlong-termnoninvasive mechanicalventilation:poorsleep pattern, hyperinﬂation,or silent chronic muscular fatigue?Sleep Breath 2014;18:225–6,http://dx.doi.org/10.1007/s11325-013-0931-3.

[2]Beyo˘gluC¸A,ÖzdilekA,ErbabacanE.“Deventilationsyndrome”inCPAPusers withobstructivesleepapnea:clinicalimpactandsolutions.In:Non-Invasive MechanicalVentilation.Theory,Equipment,ClinicalApplications.seconded; 2016.p.717–23,http://dx.doi.org/10.1007/978-3-319-21653-983. [3]Adler D, Perrig S, Takahashi H, Espa F, Rodenstein D, Pépin JL, et al.

PolysomnographyinstableCOPDundernon-invasiveventilationtoreduce patientventilator asynchrony and morning breathlessness. Sleep Breath 2012;16:1081–90,http://dx.doi.org/10.1007/s11325-011-0605-y.

[4]ArnalJM,TexereauJ,GarneroA.PracticalinsighttomonitorhomeNIVin COPDpatients.COPD2017;14:401–10,http://dx.doi.org/10.1080/15412555. 2017.1298583.

[5]FanfullaF,TaurinoAE,LupoND,TrentinR,D’AmbrosioC,NavaS.Effectof sleeponpatient/ventilatorasynchronyinpatientsundergoingchronic non-invasivemechanicalventilation.RespirMed2007;101:1702–7,http://dx.doi. org/10.1016/j.rmed.2007.02.026.

[6]Yan FG, Sforza E, Janssens JP. Respiratory patterns during sleep in obesity-hypoventilationpatientstreatedwithnocturnalpressuresupport:a preliminaryreport.Chest2007;131:1090–9,http://dx.doi.org/10.1378/chest. 06-1705.

[7]ThilleAW,RodriguezP,CabelloB,LelloucheF,BrochardL.Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 2006;32:1515–22,http://dx.doi.org/10.1007/s00134-006-0301-8.

[8]Sasaki N, Meyer MJ, Eikermann M. Postoperative respiratory muscle dysfunction: pathophysiology and preventive strategies. Anesthesiology 2013;118:961–78,http://dx.doi.org/10.1097/ALN.0b013e318288834f. [9]CassartM,PettiauxN,GevenoisPA,PaivaM,EstenneM.Effectofchronic

hyper-inﬂationondiaphragmlengthandsurfacearea.AmJRespirCritCareMed 1997;156:504–8,http://dx.doi.org/10.1164/ajrccm.156.2.9612089.

[10]LaskowskiK,StirlingA,McKayWP,LimHJ.Asystematicreviewofintravenous ketamineforpostoperativeanalgesia.CanJAnaesth2011;58:911–23,http:// dx.doi.org/10.1007/s12630-011-9560-0.

[11]ZocchiL,GarzanitiN,NewmanS,MacklemPT.Effectofhyperinﬂationand equalizationofabdominalpressureondiaphragmaticaction.JApplPhysiol 2017;62:1655–64,http://dx.doi.org/10.1152/jappl.1987.62.4.1655.

[12]BrancatisanoA,EngelLA,LoringSH.Lungvolumeandeffectivenessof inspira-torymuscles.JApplPhysiol2017;74:688–94,http://dx.doi.org/10.1152/jappl. 1993.74.2.688.