Jet ventilation for the extraction of endobronchial foreing body in a patient with drained pneumothorax: a case report/Ventilacion jet para la extraccion de un cuerpo extrano endobronquial en un paciente con neumotorax drenado: informe de caso.
High frequency jet ventilation (HFJV) is a recognized ventilation technique for surgical and endoscopic interventions on the bronchial tree, in particular after a foreign body aspiration (FBA). Even though few clinical cases were reported about its use in adults, (1) we report the case of a patient with a FBA complicated with a pneumothorax who was ventilated with HFJV for the FBA extraction.
We report a case of a 71-year old male with a history of COPD and pulmonary silicosis.
Clinical findings, diagnostic assessment and interventions
He was admitted to the emergency department of our hospital for sudden dyspnea after choking while eating, resulting in an increased work of breathing, and desaturation despite oxygen administration with reservoir mask.
A right chest tube was placed after the diagnosis of a pneumothorax on the chest X-ray and permitted to obtain a clinical improvement. Due to the persistence of an atelectasis of the left upper lobe, a chest CT scan was performed and allowed to identify a round image of 5 mm in relation with a foreign body, 3.8 mm distal to the carina, which occupied the left main bronchus (Fig. 1). Given the stable clinical situation, we decided to perform a rigid bronchoscopy to extract this foreign body under general anesthesia, using HFJV (FiO2 = 1; pressure of 2 atm; f= 150 cycles/min, and I-time of 50%), once the patient had accomplished the fasting time of 6 h.
Follow-up and result
After an uneventful procedure, the patient did not present any complication, was transferred to the post anesthetic care unit, and discharged to the ward 2 h after.
Discussion of the medical literature
Tracheobronchial FBA is uncommon in adults, compared with children. The more common aspirated materials are dental debris, appliances, or prosthesis even though food debris are also described, especially in elderly patients and patients with neurological disorders. (2)
Rigid bronchoscopy is more invasive than flexible bronchoscope, but it gives more operability to the pneumologist or the thoracic surgeon and remains the gold standard when consistent mass of material is planned to be removed, since the working channels are significantly larger. (3)
HFJV has demonstrated its usefulness especially in neonates and pediatric patients, providing adequate gas exchange and minimizing risk of chronic respiratory diseases.
In adults, it is used for anesthesia in the upper airway surgery, ensuring the ventilation of the patient through a cannula inserted into the trachea, below the surgical field, while it improves the surgeon's comfort, suppressing the movement of the surgical field. In surgical resection of the descending thoracic aortic aneurysms, with selective lung ventilation, HFJV demonstrated its interest to ensuring the oxygenation in the non-ventilated lung. Also it has been used for lung resection, left atrial ablation by percutaneous radiofrequency, lithotripsy and laparoscopic surgery. (4-6)
It has been described as well for acute respiratory failure in patients with shock, applying small tidal volumes during high frequency ventilation: the lower intrathoracic pressure minimizes the interferences with venous return to the heart. In the presence of high flow bronchopleural fistula or pneumothorax, HFJV facilitates alveolar recruitment and increases the mean pressure in the airway, but decreases peak pressure and the leak. In severe respiratory failure, HFJV can maintain higher end- expiratory volumes, increasing functional residual capacity without increasing the maximum alveolar pressure. A recent publication showed that the association of HFJV with PEEP in rabbits suffering from acute lung injury improved oxygenation. (7)
Literature concerning the interest of HFJV in the management of patients with pneumothorax is scarce. HFJV is a known cause of pneumothorax due to barotrauma, and this is the reason why monitoring airway pressures during its use is so important. However, when there is a preexistent pneumothorax, the adequate use of HFJV probably helps to reduce the air leak through the bronchopleural fistula because a lower elevation in the airway pressure, associated with a good compromise on the oxygenation. (8,9)
In the case described, rigid bronchoscopy minimized the risk of aspiration of blood and detritus due to continuous flow of gas upward, and avoided the increase of the air leak through the pneumothorax thanks to limited airway pressures, making it a clear indication and utility.
Protection of human and animal subjects. The authors declare that no experiments were performed on humans or animals for this study.
Confidentiality of data. The authors declare that they have followed the protocols of their work center on the publication of patient data.
Right to privacy and informed consent. The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.
Conflict of interests
The authors have no conflict of interests to declare.
(1.) Gonzalez MCE, Ordonez Fernandez V. Reporte de caso: quemadura de la via aerea. Rev Colomb Anestesiol. 2013; 41:226-8.
(2.) Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new? Clin Chest Med. 2001; 22:319-30.
(3.) Liberman M. Bronchoscopic evaluation of the trachea and dilation of the trachea. Semin Thorac Cardiovasc Surg. 2009; 21:255-62.
(4.) Chandradeva K, Palin C, Ghosh SM, Pinches SC. Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema. Br J Anaesth. 2005; 94:683-6.
(5.) Garcia Araque HF, Valencia Orgaz O, Lopez Vicente R, Gutierrez Vidal SE. Anatomia de la via aerea para el broncoscopista. Una aproximacion a la anestesia. Rev Colomb Anestesiol. 2014; 42:192-8.
(6.) Ihra G, Gockner G, Kashanipour A, Aloy A. High-frequency jet ventilation in European and North American institutions: developments and clinical practice. Eur J Anaesthesiol. 2000; 17:418-30.
(7.) Bang JO, Ha SI, Choi IC. The effect of positive-end expiratory pressure on oxygenation during high frequency jet ventilation and conventional mechanical ventilation in the rabbit model of acute lung injury. Korean J Anesthesiol. 2012; 63:346-52.
(8.) Ellsbury DL, Klein JM, Segar JL. Optimization of high-frequency oscillatory ventilation for the treatment of experimental pneumothorax. Crit Care Med. 2002; 30:1131-5.
(9.) Wippermann CF, Schranz D, Baum V. Huth R. Independent right lung high frequency and left lung conventional ventilation in the management of severe air leak during ARDS. Paediatr Anaesth. 1995; 5:189-92.
Julieta Latorre, Nicolas Brogly *, Genaro Maggi, Fabiola Quinteros, Natalia Pena del Ser, Fernando Gilsanz
Anesthesiology Department, Hospital Universitario La Paz, Madrid, Spain
* Please cite this article as: Latorre J, Brogly N, Maggi G, Quinteros F, Pena del Ser N, Gilsanz F. Ventilacion jet para la extraccion de un cuerpo extrano endobronquial en un paciente con neumotorax drenado: informe de caso. Rev Colomb Anestesiol. 2017; 45:140-142.
* Corresponding author at: Servicio de Anestesia y Reanimacion, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.
E-mail address: email@example.com (N. Brogly).
Received 24 August 2015
Accepted 25 November 2016
Available online 24 February 2017
Caption: Fig. 1--Computer tomography showing a foreign body at 3.8 mm from the carina, a round image of about 5 mm occupying the left main bronchus that conditions atelectasis of the left upper lobe. Minimum right pneumothorax was observed.
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|Title Annotation:||Case report|
|Author:||Latorre, Julieta; Brogly, Nicolas; Maggi, Genaro; Quinteros, Fabiola; del Ser, Natalia Pena; Gilsanz|
|Publication:||Revista Colombiana de Anestesiologia|
|Date:||Apr 1, 2017|
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