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Anesth Analg 2004;98:1813-1814
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000120088.02675.99

LETTERS TO THE EDITOR

Unsuspected Mechanical Airway Obstruction in Obstructive Sleep Apnea Syndrome

B. Çelebioglu, MD, E. Özer, MD, and V. Çeliker, MD

Department of Anesthesiology and Reanimation, Hacettepe University, School of Medicine, Ankara, Turkey

To the Editor:

Uvulopalatopharyngoplasty has been an alternative choice of surgical procedure used to treat adult patients (1–3). We report an unusual and life-threatening case of upper airway obstruction in a obstructive sleep apnea patient undergoing uvulopalatopharyngoplasty. An ASA II, slightly overweight (BMI = 28 kg/m2), 56-year-old man, with polysomnography-confirmed obstructive sleep apnea was admitted to the operating theater as an outpatient. His hypopnea-apnea index was between 10–30, which confirmed his obstructive sleep apnea symptoms. Although he had been hypertensive for about 5 years, he had no specific cardiac problems. He was taking regular antihypertensive medication. When he was taken to the operating room, he had no stridor, or rebreathing embarrassment, but he was a heavy smoker and had a thick, short neck. His blood pressure was 148/90 mm Hg, SaO2 94%.

Anesthesia was induced with propofol, and ventilation via a bag mask was confirmed easily. He was then paralyzed with vecuronium. Anesthesia was maintained with a stepwise target-controlled infusion of propofol. A size 7.5 Mallinckrodt flexible tracheal tube was used for nasotracheal intubation. His Mallampati score was 2. His trachea was intubated without any difficulty. Crowe-Dawis mouth gag (Fig. 1) was attached to the patient to obtain a better surgical view of the pharynx. This device is used regularly during uvulopalatopharyngoplasty. Hemodynamic variables (heart rate, noninvasive blood pressure, SaO2) were stable during the procedure. The surgery ended without complication. The trachea was extubated when he was fully awake and the oxygen saturation was >= 94%. Methylprednisolone (250 mg) was given to prevent glottic edema before his trachea was extubated.



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  		Figure 1. Crowe-Dawis mouth gag.

 
Having been extubated, the patient complained of difficulty in breathing. The patient became very irritable, combative, and disorientated. Within few seconds, his oxygen saturation decreased to 80%. The anesthetic team decided to check out the patient’s airway to rule out the glottic edema. Soon after, the patient was sedated to perform direct laryngoscopy. No visible glottic or soft tissue edema was detected in the oral cavity. Some bloody saliva and blood clot was suctioned from the oral cavity. Clot-like debris was observed near the glottic opening, which was very close to the laryngeal inlet. This was removed with the aid of Magill forceps. When the debris was examined closely, it was realized that it was the red-elastic rubber pad of the mouth gag.

In general, the risks posed by obstructive sleep apnea patients undergoing uvulopalatopharyngoplasty are airway obstruction and oxygen desaturation. These adverse outcomes could be due to dental problems or mechanical apne Related to massive nasopharyngeal edema. In our case, the red-elastic rubber pad of the mouth gag was the cause and was removed promptly.

We urge all anesthesia personnel to maintain a high index of suspicion of foreign body aspiration in patients who report stridorous breathing after uvulopalatopharyngoplasty.

References

  1. Lack JA. Another airway foreign body. Anaesthesia 2002; 57: 189.
  2. Bagley WP. An unusual presentation of an airway foreign body involving dentures. Anesthesiology 2002; 96: 1535.[ISI][Medline]
  3. Loadsman JA, Hillman DR. Anaesthesia and sleep apnoea. Br J of Anaesth 2001; 86: 254–66.[Abstract/Free Full Text]




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press