bronchospasm

[militarymd]

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42 year old ASA 1 for acdf...put her to sleep....develops bronchospasm after intubation...which gets worse and worse...one of the worse cases I've seen in probably 10 years....Treat her with ALL the therapies available while trying to ventilate her.

Actually gets worse after NMB was given....improved some after epi iv....sats stayed in the 60's for what seemed like hours but was probably minutes..

Cyanosis was bad enough that the "don't cancel my cases" orthopod asked if we should cancel.

Got a CXR during all this:

what does everyone think?

 

[Planktonmd]

Retrosternal goiter or other anterior mediastinal mass that caused the airway to collapse after you paralyzed the patient.
It's not bronchospasm.

what does everyone think?

 

[pgg]

Hard to see the film on my iPhone but looks like there's an opacity in the medial lul or mediastinum? Maybe a mass causing airway compression that only became apparent after induction when the patient went from neg press vent to PPV with a NMB? Ie not bronchospasm at all. Just a WAG. 🙂

 

[Eta Carinae]

Got a CXR during all this:

what does everyone think?

Thymoma
Hodgkin's Lymphoma (c/w age)
Teratoma (kind of older but...)
Thyroid mass (anatomically low)

I wonder if surg hx /anesthesia hx shows prior probs

I wonder if older CXRs to compare with?

recent med hx of nocturnal cough, SOB/DOE, orthopnea?

 

[Eta Carinae]

Other:
off the top of my head, so by no means exhaustive

ANT MEDIASTINAL
as above

MIDDLE MEDIASTINAL
exceptionally rare cardiac tumor
Lung tumor?

POSTERIOR MEDIASTINAL
Neurogenic tumor
Esophageal tumor

Swallowed a ball😀

 

[Eta Carinae]

I wonder if she has any lateral views as well.

 

[militarymd]

Thymoma
Hodgkin's Lymphoma (c/w age)
Teratoma (kind of older but...)
Thyroid mass (anatomically low)

I wonder if surg hx /anesthesia hx shows prior probs

I wonder if older CXRs to compare with?

recent med hx of nocturnal cough, SOB/DOE, orthopnea?

this is an ASA1, healthy lady who herniated a disc doing house work.....no preop cxr...other than a ap c-spine view which doesn't really get low enough.

 

[militarymd]

I wonder if she has any lateral views as well.

this film was shot in the middle of my hypoxia/hypoventilation flail.....no lateral.

 

[proman]

Were the breath sounds equal bilaterally? She probably has a CT or MRI of the cervical spine. I'd imagine a mass would have at least been partially imaged. Did you bronch her after she was stabilized?

 

[militarymd]

Were the breath sounds equal bilaterally? She probably has a CT or MRI of the cervical spine. I'd imagine a mass would have at least been partially imaged. Did you bronch her after she was stabilized?

yes....but really LOUD wheezing


we looked...nothing noted...this is after the fact


how do you know I got her stabilized?

 

[proman]

how do you know I got her stabilized?

You used past tense to describe her sats "stayed". Do you have heliox available?

 

[militarymd]

You used past tense to describe her sats "stayed". Do you have heliox available?

Could easily have "stayed" low for minutes before starting cpr...and trying to go on bypass.

and no...no heliox....

 

[deleted126335]

Could easily have "stayed" low for minutes before starting cpr...and trying to go on bypass.

and no...no heliox....

If still having trouble stabilizing patient and I had the CXR...I would turn patient prone. Try ventilating in that position and see what it does for vital signs.

 

[Planktonmd]

If still having trouble stabilizing patient and I had the CXR...I would turn patient prone. Try ventilating in that position and see what it does for vital signs.

👍
Yes.
Even lateral might solve the problem.

 

[seinfeld]

Interesting case, The CXR does show mediastinal pathology. However the ETT appears to be distal to the majority of the mass. Also given air showes up black on CXR and lack of AIR in the lungs (ie think mucous plugging causing airway obstruction) shows up White you are getting some amount of air in the lungs.

What is your compliance? ie what is your pressures and related tidal volumes. I assume something like 50 cmH2o to get 150ml of volume.

I trust when you say the patient is wheezing you mean real wheezing, not stridor, so i will ignore the potential for airway obstruction, tube blockage etc.

When you say you gave everything, what exactly did you give? Given this is a case youre willing to share, things like carcinoid should be included in the DDX. Did you give any Octreotide?

If this is merely really bad Reactive Airway disease from meds after induction. Ranitidine, Bendryl, Steroids, Inhaled anesthetic on high, Continuous Nebulizer, Epi drip, Ketamine, ? use of Mg bolus and drip. On vent tolerate higher pressures, although for longer I time. Watch for autopeep. Prepare for Ecmo. Heliox will not be effective in a patient requiring greater than 40% oxygen for as you increase the percent of Oxygen you will naturally decrease the amount of helium you can deliver.

Patient did OK in the end i hope.

 

[proman]

👍
Yes.
Even lateral might solve the problem.

I'd first try raising the back up.

 

[urge]

I'm not that impressed by that xray. Yes, it looks like there is something in the mediastinum but both lungs are well aerated. Tube is kind of low. Maybe she had a mainstem for a while plus some sort of bronchospasm, thus the sat was so low?

I would just go with good ol' allergic reaction to muscle relaxant.

You said she responded to epi. Mediastinal masses shouldn't do that.

Anyway, what did your friendly neighborhood radiologist say about the xray?

 

[militarymd]

Interesting case, The CXR does show mediastinal pathology. However the ETT appears to be distal to the majority of the mass. Also given air showes up black on CXR and lack of AIR in the lungs (ie think mucous plugging causing airway obstruction) shows up White you are getting some amount of air in the lungs.

yes

What is your compliance? ie what is your pressures and related tidal volumes. I assume something like 50 cmH2o to get 150ml of volume.

yes

I trust when you say the patient is wheezing you mean real wheezing, not stridor, so i will ignore the potential for airway obstruction, tube blockage etc.

yes

When you say you gave everything, what exactly did you give? Given this is a case youre willing to share, things like carcinoid should be included in the DDX. Did you give any Octreotide?

everything "available"....steroids, albuterol (not that much was getting in), h1 and h2 antagonist, epi......high dose sevo did not think of carcinoid ...so no octreotide...although the several times I have seen carcinoid...the bronchospasm was not this severe without other signs.

If this is merely really bad Reactive Airway disease from meds after induction. Ranitidine, Bendryl, Steroids, Inhaled anesthetic on high, Continuous Nebulizer, Epi drip, Ketamine, ? use of Mg bolus and drip. On vent tolerate higher pressures, although for longer I time. Watch for autopeep. Prepare for Ecmo. Heliox will not be effective in a patient requiring greater than 40% oxygen for as you increase the percent of Oxygen you will naturally decrease the amount of helium you can deliver.

Agree with heliox....no way I could have used it even if I had it.

 

[militarymd]

I'm not that impressed by that xray. Yes, it looks like there is something in the mediastinum but both lungs are well aerated. Tube is kind of low. Maybe she had a mainstem for a while plus some sort of bronchospasm, thus the sat was so low?

I would just go with good ol' allergic reaction to muscle relaxant.

You said she responded to epi. Mediastinal masses shouldn't do that.

Anyway, what did your friendly neighborhood radiologist say about the xray?

I was not expecting to find anything on the CXR....was wanting to rule out SEVERE alveolar collapse, pneumo....other red herring stuff.....so I didn't look at it until the radiologist called into the room to inform me that the patient had what appeared to be an anterior or middle mediastinal mass.

 

[urge]

Mil,

Now that you have that info from radiology, how was the patient doing?

 

[veetz]

42 year old ASA 1 for acdf...put her to sleep....develops bronchospasm after intubation...which gets worse and worse...one of the worse cases I've seen in probably 10 years....Treat her with ALL the therapies available while trying to ventilate her.

Actually gets worse after NMB was given....improved some after epi iv....sats stayed in the 60's for what seemed like hours but was probably minutes..

Cyanosis was bad enough that the "don't cancel my cases" orthopod asked if we should cancel.

Got a CXR during all this:

what does everyone think?

Interesting case. Pt did not mention any 'intolerance' to the supine position in the preop eval?

 

[militarymd]

Interesting case. Pt did not mention any 'intolerance' to the supine position in the preop eval?

she was on her back when I examined her.........as a medical professional.

 

[ProRealDoc]

Retrosternal goiter or other anterior mediastinal mass that caused the airway to collapse after you paralyzed the patient.
It's not bronchospasm.

I concur

 

[2win]

42 year old ASA 1 for acdf...put her to sleep....develops bronchospasm after intubation...which gets worse and worse...one of the worse cases I've seen in probably 10 years....Treat her with ALL the therapies available while trying to ventilate her.

Actually gets worse after NMB was given....improved some after epi iv....sats stayed in the 60's for what seemed like hours but was probably minutes..

Cyanosis was bad enough that the "don't cancel my cases" orthopod asked if we should cancel.

Got a CXR during all this:

what does everyone think?

Very interesting. The mass is seen on CXR and extends bellow the tip of the ETT. What I don't understand is why the "bronchospasm" got worst after the NMD - "develops bronchospasm after intubation" - I suppose that you intubated after she was fully paralyzed so the obstruction got worse after the first dosage of muscle relaxant. I would say that the bronchospasm was noticed after the ett was placed and I would guess that was present after the first administration of muscle relaxant. One solution after you digested the data (including the film) is to intubate selectively in the main right bronchus and to see how it works. ASA1 , no lung pathology and a fast surgeon - I think she's able to tolerate one lung ventilation. A left lung intubation will be more reasonable but on this plain fils seems that the mass is more on the left. Another concern will be cardiac compression by the mass - and all the goodies coming with that.
But because I am not a hero and the surgery is elective I would behave the same. Remove the mass (with an adequate plan for anesthesia) and later proceed with the ACF.
On an academic point of view - I think is interesting to measure the Palv. Also for the fun - stridor versus wheezing...
2win

 

[Planktonmd]

The reason why he called it bronchospasm is because he is trying to confuse people, and possibly because he does not know how to distinguish between expiratory wheezing in real bronchospasm and the inspiratory noise caused by bronchial obstruction.
By the way there is no way on earth that a patient like the one represented in the CXR could be asymptomatic pre-op.

Very interesting. The mass is seen on CXR and extends bellow the tip of the ETT. What I don't understand is why the "bronchospasm" got worst after the NMD - "develops bronchospasm after intubation" - I suppose that you intubated after she was fully paralyzed so the obstruction got worse after the first dosage of muscle relaxant. I would say that the bronchospasm was noticed after the ett was placed and I would guess that was present after the first administration of muscle relaxant. One solution after you digested the data (including the film) is to intubate selectively in the main right bronchus and to see how it works. ASA1 , no lung pathology and a fast surgeon - I think she's able to tolerate one lung ventilation. A left lung intubation will be more reasonable but on this plain fils seems that the mass is more on the left. Another concern will be cardiac compression by the mass - and all the goodies coming with that.
But because I am not a hero and the surgery is elective I would behave the same. Remove the mass (with an adequate plan for anesthesia) and later proceed with the ACF.
On an academic point of view - I think is interesting to measure the Palv
2win

 

[militarymd]

by the time that the radiologist called me with the result...I was ventilating a little better...sats in the 90's....

So the question is....what to do now....

- go to unit with tube
- wake up extubate..


btw...I intubated with sux....then followed by roc ....when I had difficulty with ventilation.

 

[Planktonmd]

btw...I intubated with sux....then followed by roc ....when I had difficulty with ventilation.

😱
Why would you give Roc if you can't ventilate after Sux??

 

[Eta Carinae]

Also for the fun - stridor versus wheezing...
2win

expiratory wheezing in real bronchospasm and the inspiratory noise caused by bronchial obstruction.
By the way there is no way on earth that a patient like the one represented in the CXR could be asymptomatic pre-op.

I could be wrong but my understanding is that

stridor is mostly inspiratory in nature (can be both insp&exp) and results from upper airwary obstruction

wheezing, on the other hand, results from obstruction of the lower airways is expiratory in nature and occurs concurrently with a prolonged expiratory phase.

As such, the patient's imaging would be consistent with the phys ex finding of wheezing.

Again, I could be wrong.

 

[Arch Guillotti]

😱
Why would you give Roc if you can't ventilate after Sux??

Unrecognized anterior mediastinal mass is a zebra for sure, esp in someone who is purportedly asymptomatic. I don't know that I would consider it immediately based on the scenario given.

Whether or not I give roc depends on how exactly the induction played out. If sux was given and the patient was hard to ventilate, I would just go ahead and intubate - which is what I presumed happened. If the patient is hard to ventilate and hard to intubate then I would think about waking up. If the patient is successfully intubated, yet still having problems chances are I would go ahead with the roc. Once the tube is secure I don't see anything wrong with giving the roc with the information at hand.

 

[Planktonmd]

This is a mediastinal mass with compression of the trachea and main bronchi, and those are not "lower airway".

wheezing, on the other hand, results from obstruction of the lower airways is expiratory in nature and occurs concurrently with a prolonged expiratory phase.

As such, the patient's imaging would be consistent with the phys ex finding of wheezing.

Again, I could be wrong.

 

[deleted126335]

😱
Why would you give Roc if you can't ventilate after Sux??

-wouldn't hesitate to give roc. NMB dramatically lowers Oxygen consumption. More than enough reason by itself in a patient this unstable. SUX wearing off soon.
Another possibility is anaphylaxis with the CXR being a red herring. Assuming not since you didn't mention hives/flushing. I would be leaning that way without and before CXR. I saw that you treated for it in any case.

 

[Arch Guillotti]

I could be wrong.

🙄

 

[deleted126335]

by the time that the radiologist called me with the result...I was ventilating a little better...sats in the 90's....

So the question is....what to do now....

- go to unit with tube
- wake up extubate..


btw...I intubated with sux....then followed by roc ....when I had difficulty with ventilation.

I would try to get patient breathing spontaneously in OR. Coming off positive pressure ventilation and NMB might dramatically improve situation. IF able to do well on spont vent---> extubate. If not to ICU vented.

 

[Arch Guillotti]

I would try to get patient breathing spontaneously in OR. Coming off positive pressure ventilation and NMB might dramatically improve situation. IF able to do well on spont vent---> extubate. If not to ICU vented.

I definitely would not proceed with the case.

 

[2win]

-wouldn't hesitate to give roc. NMB dramatically lowers Oxygen consumption. More than enough reason by itself in a patient this unstable. SUX wearing off soon.
Another possibility is anaphylaxis with the CXR being a red herring. Assuming not since you didn't mention hives/flushing. I would be leaning that way without and before CXR. I saw that you treated for it in any case.

"NMB dramatically lowers Oxygen consumption" - another great discussion - controversial. Let's bring some studies.
Why to give roc if you have difficulties ventilating? If you are concerned about inadequate relaxation you can check it up with a nerve stimulator....Maybe the wrong batch of sux or kinked IV...
Now - I noticed at M&M cases that people are very judgmental and the truth is that, is very easy to judge being not involved in the case....
For example - in this case - in real life you don't put the diagnosis of obstruction or bronchospasm (you see that you cannot ventilate though) and you proceed with intubation. You move also fast and concerned - could be a difficult intubation - careful with the neck - spine pathology. You notice the bronchospasm after...I saw it so I know what I am talking about. You adjust the plan fast...

 

[Planktonmd]

If you just induced and gave Sux you have a good 5-10 minutes of excellent muscle relaxation so if during these 5-10 minutes you can not ventilate there is no reason to assume that giving any other muscle relaxant is going to help you.
The only situation where muscle rigidity after sux could be considered is if you are suspecting MH (obviously not the case here) and in that case giving ROC would not help anyway.
Actually if you are suspecting severe bronchospasm as he said then you should avoid anything that could cause hisatmine release and complicate the situation further at least in the first stages.
I would have concentrated on deepening the anesthetic and treating the suspected bronchospasm if I were in his shoes.
Again there is no way on earth this patient was asymptomatic from this huge mediastinal mass pre-op.

chances are I would go ahead with the roc. Once the tube is secure I don't see anything wrong with giving the roc with the information at hand.

-wouldn't hesitate to give roc. NMB dramatically lowers Oxygen consumption. More than enough reason by itself in a patient this unstable. SUX wearing off soon.

 

[Arch Guillotti]

If you just induced and gave Sux you have a good 5-10 minutes of excellent muscle relaxation so if during these 5-10 minutes you can not ventilate there is no reason to assume that giving any other muscle relaxant is going to help you.
The only situation where muscle rigidity after sux could be considered is if you are suspecting MH (obviously not the case here) and in that case giving ROC would not help anyway.
Actually if you are suspecting severe bronchospasm as he said then you should avoid anything that could cause hisatmine release and complicate the situation further at least in the first stages.
I would have concentrated on deepening the anesthetic and treating the suspected bronchospasm if I were in his shoes.
Again there is no way on earth this patient was asymptomatic from this huge mediastinal mass pre-op.

all good points.

I am curious to know what the initial dose of sux was, and at what point the roc was given.

 

[2win]

all good points.

I am curious to know what the initial dose of sux was, and at what point the roc was given.

I bet it was 1 - 1.5 mg/kg sux. The question is - do we have muscle relaxation?
Or you suspect that the dose of sux was suboptimal?
And here is the nerve stim again...
I have to recognize that for an ACF without the need of EMG-s (NO relaxation) - I push the roc after the sux and I don't check. I don't see the reason to check (Miller...) the TOF - the surgery will last at least 90 minutes....

 

[militarymd]

all good points.

I am curious to know what the initial dose of sux was, and at what point the roc was given.

100 mg....how do I know...because that's what I always give.

roc was given when the patient started resisting attempts at mechanical/assisted ventilation.

 

[militarymd]

I would try to get patient breathing spontaneously in OR. Coming off positive pressure ventilation and NMB might dramatically improve situation. IF able to do well on spont vent---> extubate. If not to ICU vented.

So that's what I did....let the nmb wear off....let the patient resume spont ventilation.

And emerged slowly with a narcotic type wake up.

She was wheezing the entire time....inspiratory and expiratory...with obvious airway obstruction on the capnogram...bronchoscopy was unrevealing...just some large a/w collapse on expiration...which is what you expect on expiration with some one who has bronchospasm.

 

[militarymd]

It was the end of the day, so the surgeon was ready to go.....I told him I would take care of the patient until pulmonary came to see her.

CT scan ordered and done while she is in the PACU.

Here are some of the relevant images.

 

[2win]

It was the end of the day, so the surgeon was ready to go.....I told him I would take care of the patient until pulmonary came to see her.

CT scan ordered and done while she is in the PACU.

Here are some of the relevant images.

Awesome - looks that a selective lung intubation is a feasible approach. Thanks mmd.

 

[militarymd]

How interesting....not many replies or comments on the images.

So anyways..the patient is doing fine in the recovery room by the time the scans are on the computer.

I look at them....and look at them....and then looked at it some more....

finally I had to go and hunt down the radiologist on call.

I say to him "can you show me the mass in there, I can't find it"


He looked...and said "this is a normal ct scan"..


I pulled up the cxr, and said.."that film was shot 90 minutes before the CT was done".

We verify that it is the same patient...and that indeed the ct scan was normal....other then minor stuff ...like subsegmental atelectasis that is seen in 100% of patients who had just emerged from GA...lack of contrast uniformity, etc.

 

[gaspasser2004]

When I was an intern doing internal medicine, a case was presented to us that involved a young man with a huge mediastinal mass. He would come in symptomatic, get a chest x-ray that would show a huge mass and then get a CT scan that would turn up negative. This scenario played out during a couple of different hospital admissions until someone figured out that the young man's mass was seminoma mets that was extremely sensitive to radiation, even the small amount in the chest x-ray. So he would come in with a true mediastinal mass, get a chest x-ray to see what was going on, they would see a mass and order a CT. By the time they got around to getting the CT, he was "cured".

Obviously, this case is different because the patient is female and only 90 minutes elapsed between CXR and CT scan, but it made me think of that young man.

 

[deleted126335]

How interesting....not many replies or comments on the images.

Not surprising. Most anesthesiologists (including me) can't read CT scans very well. So what happened? What is the "official" radiology read of the CXR?

 

[SleepIsGood]

Did you extubte this patient before going to PACU/icu?


Assuming, some sort of allergic rxn.

 

[Planktonmd]

Why do I have a feeling that this story is starting to acquire a fictional flavor?

 

[militarymd]

I'm not that impressed by that xray. Yes, it looks like there is something in the mediastinum but both lungs are well aerated. Tube is kind of low. Maybe she had a mainstem for a while plus some sort of bronchospasm, thus the sat was so low?

I would just go with good ol' allergic reaction to muscle relaxant.

You said she responded to epi. Mediastinal masses shouldn't do that.

Anyway, what did your friendly neighborhood radiologist say about the xray?

there's always a guy in every thread who gets it right...like doze with the psych thing.

Just plain old undiagnosed asthma for this one

 

[militarymd]

Not surprising. Most anesthesiologists (including me) can't read CT scans very well. So what happened? What is the "official" radiology read of the CXR?

I looked at the cxr with one radiologist when it was first done.....ant/mid mediastinal mass....

another one did the dictation....added pulmonary parenchymal mass as a possibility.

bottom line...it was atelectasis...albeit in an unusual location...she was treated for asthma for 24 hours...and surgery was done the next day without problems....other than mild bronchospasm...

follow up cxr....normal.

sometimes high take off of pulmonary lung segments...particularly RUL can lead to segmental collapse with a properly positioned ett, but the CT shows normal bronchial anatomy..

 

[militarymd]

Did you extubte this patient before going to PACU/icu?


Assuming, some sort of allergic rxn.

The CT scan gives you the answer.