Anesth Analg 2000;90:62
© 2000 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Intraoperative Desaturation and Unilateral Breath Sounds During Nissen Fundoplication
Lucinda L. Everett, MD, FAAP*, and
Stephanie E. Spottswood, MD
*Department of Anesthesiology, University of Washington and Children’s Hospital and Regional Medical Center, Seattle, Washington; and
Department of Radiology, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia
Address correspondence and reprint requests to Lucinda L. Everett, MD, Department of Anesthesiology, Children’s Hospital and Regional Medical Center, 4800 Sandy Point Way NE, Seattle, WA 98125. Address e-mail to levere{at}chmc.org
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Introduction
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The unilateral loss of breath sounds during the administration of general anesthesia may have various causes. This is a case report of a child undergoing Nissen fundoplication, during which the esophageal dilator used to adjust the size of the fundoplication was found to cause extrinsic bronchial compression with collapse of the left lung.
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Case Report
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A 9-mo-old, 5.8-kg male infant presented for Nissen fundoplication. The patient was born at term and diagnosed with 4P- syndrome [Wolf-Hirschhorn syndrome, which may include mental retardation, seizures, and cleft palate (1)]. At 5 mo of age, the patient underwent cleft palate repair and gastrostomy tube placement, at which time he required postoperative ventilation for 2 days because of hypotonia and marginal oxygenation. The patient was chronically treated with phenytoin and phenobarbital for a seizure disorder.
The child was readmitted at age 9 mo with episodes of apnea and cyanosis, and a gastric emptying study showed severe reflux. The patient was started on metoclopramide and scheduled for Nissen fundoplication. On physical examination, he was small for his age, hypotonic, and he had moderate upper airway noise that cleared with jaw positioning. His resting respiratory rate was 32 breaths/min, room air oxygen saturation was 94%–97%, and chest radiograph results were normal.
An inhaled induction was performed, peripheral IV started, and atracurium used to facilitate endotracheal intubation. He was tracheally intubated with a 3.5-mm oral endotracheal tube under direct vision, with bilateral breath sounds both initially and when he was returned to the supine position after the placement of a caudal epidural catheter. After surgical preparation and drape, a 30F bougie was placed in the esophagus at the request of the surgeon for use in sizing the fundoplication. Before incision, oxygen saturation decreased to 96% with a fraction of inspired oxygen of 1.0. Auscultation revealed decreased breath sounds on the left. The endotracheal tube was withdrawn 1 cm and suctioned, without improvement in breath sounds or saturation. A chest radiograph was obtained (Figure 1), which showed complete opacification of the left hemithorax, consistent with collapse of the left lung. The endotracheal tube was in satisfactory position within the trachea, which was displaced to the right by the large dilator. The child remained hemodynamically stable during the entire period.
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Figure 1. Supine anteroposterior portable chest radiograph suggests extrinsic compression of the left mainstem bronchus by the large caliber esophageal dilator, resulting in bronchial obstruction and left lung collapse.
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The esophageal bougie was removed, and with manual ventilation, breath sounds were again heard on the left. Oxygenation improved to a saturation of 99% on 50% oxygen. The remainder of surgery proceeded uneventfully. The extubation failed at the end of surgery, primarily as a result of upper airway soft tissue obstruction, and the child required elective reintubation in the operating room. A repeat chest radiograph (Figure 2) showed reexpansion of the left lung. The patient was extubated the following day without difficulty.
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Figure 2. Supine anteroposterior portable chest radiograph obtained 8 h after dilator extraction reveals complete reexpansion of the left lung.
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Discussion
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The clinical course and radiographic findings in this case suggest that transient lung collapse occurring intraoperatively was a result of extrinsic pressure on the posterior wall of the left mainstem bronchus by the large-caliber esophageal bougie, causing bronchial obstruction. When the bougie was removed, the left lung was reexpanded.
The differential diagnosis of unilateral breath sounds intraoperatively would include endobronchial intubation, mucous plugging, pneumothorax, and severe airspace disease (2). Aspiration of a large food particle or iatrogenic introduction of an airway foreign body could also cause mainstem bronchial occlusion. Extrinsic airway compression may occur in infants and small children as a result of vascular rings, esophageal foreign body, or lymphadenopathy (3). In small infants, during thoracic or airway procedures, manual or instrument compression of the airway by the surgical procedure is also possible. In this case, extrinsic compression of the mainstem bronchus by the bougie caused the collapse of the left lung. This phenomenon has also been reported with the use of transesophageal echocardiography in small infants (4). Clinicians using either transesophageal echocardiography probes (5) or large esophageal dilators in infants should be aware of the potential for airway obstruction.
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References
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Battaglia A, Carey JC, Cederholm P, et al. Natural history of Wolf-Hirschhorn syndrome: experience with 15 cases. Pediatrics 1999;103:830–6.[Abstract/Free Full Text]
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Don H. Hypoxemia and hypercapnia during and after anesthesia. In: Gravenstein N, Kirby R, eds. Complications in anesthesiology. 2nd ed. Philadelphia:Lippencott-Raven, 1996:251–70.
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Rencken I, Patton WL, Brasch RC. Airway obstruction in pediatric patients: from croup to BOOP. Radiol Clin N Am 1998;36:175–87.[Medline]
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Ho AC, Tan PP, Yang MW, et al. Airway compression by a biplane pediatric transesophageal echocardiography probe: case report. Chang Keng I Hsueh 1998;21:333–7.
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Stevenson JG, Sorensen GK. Proper probe size for pediatric transesophageal echocardiography. J Cardiol 1993;72:491–2.
Accepted for publication September 13, 1999.
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Introduction
Case Report
