|Year : 2018 | Volume
| Issue : 2 | Page : 81-84
Congenital lobar emphysema: Anesthetic challenges and their management options
Aparna Hemraj Yadav, Sameer Jayant Ghotavadekar
Department of Anaesthesia and Critical Care, Surya Mother and Child Care Superspeciality Hospital, Pune, Maharashtra, India
|Date of Submission||18-Jul-2018|
|Date of Acceptance||02-Aug-2018|
|Date of Web Publication||15-Nov-2018|
Dr. Aparna Hemraj Yadav
Department of Anaesthesia and Critical Care, Surya Mother and Child Care Superspeciality Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Congenital lobar emphysema (CLE) is a rare cause of sudden respiratory distress in infants. It poses a diagnostic and therapeutic dilemma. Hyperinflation and progressive air trapping causes expansion of the affected lobe leading to compression of other lung tissue, mediastinal shifting, and impaired venous return. We report a case of a 5 weeks old male infant with CLE. The left upper lobectomy was performed under general anesthesia with intercostal nerve block and pressure control ventilation. The anesthetic challenges and various management options are discussed here.
Keywords: Congenital lobar emphysema, hyperinflation, mediastinal shift, single-lung ventilation
|How to cite this article:|
Yadav AH, Ghotavadekar SJ. Congenital lobar emphysema: Anesthetic challenges and their management options. Indian Anaesth Forum 2018;19:81-4
| Introduction|| |
Congenital lobar emphysema (CLE) is a rare congenital malformation of the lung,, characterized by normal architecture with lobar over aeration and subsequent respiratory distress secondary to partial obstruction of the bronchus through ball valve effect. Its incidence is 1 in 70,000–1 in 90,000 live births. Anesthesia for CLE is challenging in terms of the age group and the severity of cardiorespiratory distress of the patients. Attempts to maintain spontaneous respiration may not be successful, and the institution of positive pressure ventilation has the potential of worsening the underlying condition.
| Case Report|| |
A 5 weeks old male infant, born of a full-term cesarian delivery with birth weight of 3 kg, was referred to our hospital with the diagnosis of the left upper lobe CLE, for further management. On examination, the patient was tachypnoeic with a respiratory rate of 54–60/min. The baby was in respiratory distress with subcostal retractions. SpO2 on room air was 86%–89%. The cardiac impulse was shifted to right. On auscultation, air entry was reduced on the left side, and heart sounds were shifted to right. Heart rate was 154/min, blood pressure of 88/55 mmHg. Capillary return was good with all the peripheral pulses palpable. The chest radiography [Figure 1] showed hyperinflation of the left lung, mediastinal shift toward the right, and small atelectatic right lung. The CT scan [Figure 2] further confirmed the diagnosis of the left upper lobe CLE. The patient was stabilized in pediatric intensive care unit (PICU) with oxygen supplementation, IV antibiotics, bronchodilators, and nebulization. The arterial blood gas analysis showed respiratory acidosis with the rest of the laboratory findings within normal limits. The left upper lobectomy was planned the next morning.
|Figure 1: Chest radiograph showing hyperinflated left lung with mediastinal shift towards right and small atelectatic right lung|
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In the operation theater, continuous arterial blood pressure monitoring and rest all routine monitors such as rectal temperature, pulsoximeter, and electrocardiography were established. Injection glycopyrrolate 15 mcg and injection dexamethasone 0.6 mg was given in the form of premedication. Injection fentanyl 5 mcg was used as analgesic. Spontaneous inhalational induction was begun with sevoflurane by incremental method. The surgeons were asked to be ready for emergency thoracotomy if any need was to arise. The baby was intubated with size 3.5 single lumen uncuffed portex endotracheal tube (ETT) and injection atracurium 1.5 mg was given. The patient was ventilated with pressure control ventilation with oxygen, air, and sevoflurane. The left upper lobectomy was performed by the surgeon and intercostal nerve block with 2.5 ml of 0.25% bupivacaine was administered. An ICD was placed on the left side. The patient was shifted to PICU for elective ventilation for 24 h and gradually weaned off the ventilator on the 2nd post operative day [Figure 3].
|Figure 3: Post operative day two chest radiograph showing good expansion of both lungs|
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| Discussion|| |
CLE is a rare cause of sudden respiratory distress in infants. Hyperinflation and progressive air trapping causes expansion of the affected lobe leading to compression of other lung tissue, mediastinal shifting and impaired venous return. The most commonly affected is left upper lobe followed by right middle and upper lobes. Occasionally, more than one lobe is affected. The cause of obstruction is unknown in most cases, although many show evidence of deficient and disordered bronchial cartilage. In some cases, there are identifiable causes of bronchial compression such as aberrant blood vessels, bronchial cysts, and bronchial stenosis. Our patient did not have any other congenital abnormalities.
CLE usually appears clinically in the first 6 months of life with tachycardia, tachypnea, and retractions. Physical examination reveals the asymmetric expansion of thorax, wheezing, displacement of cardiac impulse, hyperresonance to percussion, and diminished breath and heart sounds. Chest radiographs show overdistention of the affected lobe, mediastinal shift, and atelectasis in other lobes. CLE is commonly misinterpreted as pneumothorax by many clinicians.,, Chest radiographs can help differentiate lobar emphysema from pneumothorax or congenital cysts by the presence of faint bronchovascular markings and herniation of the affected lobe across the midline. Computed tomography can be done to confirm the diagnosis before surgery.
Various induction and maintenance strategies of anesthesia have been described in the literature. Induction is particularly challenging in these cases as crying or struggling child leads to hyperventilation and air trapping which further aggravates emphysema. Challenges are both respiratory and cardiovascular. Intermittent positive pressure ventilation (IPPV) also can expand the emphysematous lobe. Increased intrathoracic pressure may lead to cardiovascular compromise. Therefore, spontaneous and smooth inhalational induction with sevoflurane is usually the preferred method of induction. Intubation can be performed with or without the use of muscle relaxants depending on patient's tolerance of positive pressure ventilation and anesthesiologist's preference. Sreevastava and Kiran have preferred the placement of a double lumen tubes (DLTs) after giving muscle relaxant with assisted ventilation. We have used spontaneous inhalational technique of induction with sevoflurane in oxygen and avoided the use of muscle relaxant for intubation.
Some anesthetists avoid the use of controlled ventilation until thoracotomy is done and the diseased lung is isolated.,,,, The key anesthetic concern in such patients is to avoid overdistention of the emphysematous lobe before the chest is opened. Single-lung ventilation, despite of being the ideal choice, is technically very difficult to achieve in this age group. DLTs are not commercially available in this much smaller size. Correct placement of bronchial blockers is a challenging task. There is a choice of endobronchial intubation with the single-lumen ETT. However, single-lung ventilation may not be sufficient to maintain adequate oxygenation in all the patients. We have used single-lumen ETT and pressure controlled ventilation with pressures just adequate to maintain SpO2100% without lung isolation.
Nitrous oxide is avoided,,,, due to its property of expansion of the hollow spaces such as emphysematous lobe here. We have used a combination of oxygen and air in 50%–50% concentration.
High-frequency ventilation is another ventilation strategy that can be used in these cases. It allows the use of low ventilation pressures and hence achieving better-operating conditions for surgeons. It is recommended if circumstances permit and the user is familiar with the technique.
Caudal epidural catheter placement,, can be used for intra- and post-operative analgesia. It has its own learning curve and risks such as infection, inadvertent spread of the block. We have preferred intercostal nerve blockade which can be easily administered by the surgeon under vision in open chest, is more specific to the area of interest. Our pediatrician colleagues had used fentanyl infusion for postoperative sedation and analgesia.
Nasal intubation can be preferred in such cases as the tube is better tolerated by the patients in case need of postoperative ventilation arises. These patients can be extubated immediately after the surgery or can be shifted for elective ventilation depending on surgical conditions and anesthesiologists preference. We have shifted the baby to PICU for elective ventilation till adequate expansion of the healthy lung was achieved.
| Conclusion|| |
CLE is a rare cause of respiratory distress in infants. It poses various challenges for the anesthesiologist from induction till extubation. Spontaneous inhalational induction and pressure control ventilation can be used with low pressures. The use of nitrous oxide is better avoided. Intercostal nerve block is a good alternative to neuraxial blockade for analgesia. Elective postoperative ventilation leads to early and good expansion of healthy lung tissue.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
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