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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 8  |  Page : 684-685  

Unusual cause of intraoperative high airway pressures due to chest wall compression by the breast positioner (Allen table)


1 Department of Anaesthesia, 5th Floor, Medical College Building, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Paediatrics, 5th Floor, Medical College Building, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Web Publication9-Aug-2019

Correspondence Address:
Dr. Priyanka Gupta
Department of Anaesthesia, 5th Floor, Medical College Building, All India Institute of Medical Sciences, Rishikesh - 249 201, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_289_19

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How to cite this article:
Biswas S, Khan A, Gupta P, Gupta G. Unusual cause of intraoperative high airway pressures due to chest wall compression by the breast positioner (Allen table). Indian J Anaesth 2019;63:684-5

How to cite this URL:
Biswas S, Khan A, Gupta P, Gupta G. Unusual cause of intraoperative high airway pressures due to chest wall compression by the breast positioner (Allen table). Indian J Anaesth [serial online] 2019 [cited 2019 Aug 21];63:684-5. Available from: http://www.ijaweb.org/text.asp?2019/63/8/684/264203



Sir,

We herewith report about a 10-year-old girl weighing 25 kg, who presented with severe kyphosis deformity of D4–D11 vertebrae due to previous tubercular infection [Figure 1]a. She was posted for multiple vertebral fusion under general anaesthesia in prone position. This child also had pectus carinatum [Figure 1]b. Pulmonary function test revealed severe restrictive abnormality with FEV1 of 25%, FVC of 28% and FEV1/FVC of 93% of the predicted value. Transthoracic echocardiography was normal and baseline SpO2 was 96% on room air. Other investigations were within normal limits.
Figure 1: (a) Severe kyphosis (b) Pectus carinatum

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In the operation theatre, ECG, NIBP and SpO2 were attached and anaesthesia was induced with intravenous (IV) fentanyl, propofol and vecuronium and the trachea was intubated with 6.0-mm cuffed, flexometalic tube. Following induction of anaesthesia, 6-Fr triple lumen central line was inserted into the right internal jugular vein under USG guidance and the left radial artery was cannulated with 22G cannula. The patient was turned prone on an Allen spine table (Allen table A-70270 Contour™). Bilateral air entry was confirmed again and the lungs were ventilated with volume control mode, tidal volume (TV) 150 mL and frequency 14/min. Peak airway pressure (Ppeak) was 17 cm H2O and plateau pressure (Pplat) was 15 cm H2O. By about fourth hour of surgery, Ppeak gradually increased to 28 cm H2O and Pplat to 27 cm H2O. Delivered tidal volume and minute ventilation both were reduced and end tidal carbon dioxide (ETCO2) rose to 39 mmHg. Endotracheal tube migration or obstruction/kinking and respiratory secretions were all excluded by passing a 10-Fr suction catheter through the endotracheal tube smoothly. However, airway pressure continued to rise to 35 cm H2O, TV reduced to 25 mL and ETCO2 rose to 45 mmHg. Meanwhile the patient also developed tachycardia (HR = 130–150/min). Considering bronchospasm as the possible cause, nebulised levo-salbutamol was given and 50-mg inj. Hydrocortisone IV was administered. Manual ventilation was tried, but there was significant resistance while attempting to ventilate. Despite all measures, airway pressure continued to be high and patient's ventilation remained inadequate. At this point, it was decided to turn patient into supine position. The incision was temporarily closed and the patient was turned supine. Immediately on turning the patient supine, Ppeak reduced to 19 cm H2O and Pplat 18 cm H2O, minute ventilation improves to 1.9 L/min and tachycardia settled down to 86 beats/min. Suctioning of ET tube and oral cavity revealed nothing. Endotracheal tube was exchanged with same size flexometalic tube; there was no sign of biting or kinking of tube. Careful monitoring of all equipment and breathing circuit showed no abnormality.

At this point, it was observed that the breast positioner of Allen spine table (Allen table A-70270 Contour™) [Figure 2]a was still attached to the table. After its removal [Figure 2]b, patient was again made prone. Airway pressure was unchanged (18 cm H2O); the lungs could be adequately ventilated and the patient remained hemodynamically stable. The surgery continued for another 3.5 h without any complication. Patient was shifted to PACU for overnight ventilation and trachea was extubated next day. We inferred that breast positioner led to compression of the compliant and soft chest wall, which could have led to increased airway pressures.
Figure 2: (a) Allen spine table (A-70270 Contour™) with breast positioner. (b) Allen spine table (A-70270 Contour™) without breast positioner

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To our best knowledge, there is no such reported incident; however, intraoperative airway obstruction has been reported in the patients undergoing scoliosis surgery, particularly who have associated neuromuscular disorder such as Duchene muscular dystrophy[1] and Marfan's syndrome.[2]

The contour Breast positioner is a prone chest support designed to accommodate large breasted female patient. We conclude that before positioning children in prone position, this attachment must be removed to avoid such complication.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Yang JH, Bhandarkar AW, Lim BG, Modi HN, Suh SW. Intraoperative airway obstruction in a Duchenne muscular dystrophy patient. Eur Spine J 2013;22:491-6.  Back to cited text no. 1
    
2.
Oh AY, Kim YH, Kim BK, Kim HS, Kim CS. Unexpected tracheomalacia in Marfan syndrome during general anesthesia for correction of scoliosis. Anesth Analg 2002;95:331-2.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2]



 

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