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Iatrogenic pneumothorax during hypoglossal nerve stimulator implantation
Am J Otolaryngol xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto
Iatrogenic pneumothorax during hypoglossal nerve stimulator implantation☆ ⁎
Alberto A. Arteaga , Kristen D. Pitts, Andrea F. Lewis Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, MS, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Hypoglossal nerve stimulator Obstructive sleep apnea Surgical treatment of obstructive sleep apnea Sleep surgery Iatrogenic pneumothorax
Hypoglossal nerve stimulation is a promising new treatment for patients with obstructive sleep apnea. In the initial Stimulation Therapy for Apnea Reduction Trial, the overall rate of serious adverse events was < 2% and no cases of pneumothorax were reported. We present the case of an iatrogenic pneumothorax during placement of the chest sensor lead between the intercostal muscles. Following clinical and radiological evaluation, surgery was continued and the patient was treated expectantly. In the following review, we discuss pathophysiology, diagnosis, and expected outcomes. Surgeons placing hypoglossal nerve stimulators should be aware of complications and prepared to manage a pneumothorax.
1. Introduction Obstructive sleep apnea is a relatively common sleep disorder characterized by repetitive upper airway collapse during sleep that results in a variety of comorbidities that affect quality of life and cardiovascular risk. Current treatments aim to improve sleep quality and decrease comorbidities associated with OSA. Upper airway stimulation (UAS) therapy is an alternative for patients unable to tolerate first line treatment with continuous positive airway pressure (CPAP) who meet specific severity and phenotypic criteria. UAS therapy has been shown to be a relatively safe procedure with a low incidence of perioperative adverse events [1, 2]. As more cases are being performed, it is important to report unexpected complications in order to refine the surgical technique, prevent reoccurrence of complications as well as to know how to treat them. We present the case of a 52-year-old male who developed an iatrogenic pneumothorax (PTX) during the placement of the chest sensor lead and a brief review of the diagnosis and management or iatrogenic pneumothorax. 2. Case report A 52-year-old male (AHI = 26.9, BMI = 30.24) unable to tolerate CPAP therapy, underwent Inspire® hypoglossal nerve stimulator surgery for treatment of his obstructive sleep apnea. During the creation of the tunnel for chest lead insertion, a rush of air was heard while the
malleable retractor was being advanced between the internal and external intercostal muscles. The retractor was immediately removed and an occlusive dressing, moist gauze and Tegaderm®, was applied to the site. As the patient was being monitored by the Anesthesiologist during the event, the patient never experienced oxygen desaturations or significant changes in tidal volumes or airway pressure. An intraoperative chest x-ray (CXR) was obtained and demonstrated a small pneumothorax. An intraoperative consult was placed to Thoracic surgery. Due to the small nature of the pneumothorax, there was no need for drainage with a pigtail or placement of a chest tube. As it was felt the visceral pleura was not violated and no signs of tension pneumothorax were evidenced, positive pressure ventilation was maintained throughout the procedure. After a discussion with Thoracic surgery, the chest lead was re-inserted in the proper position between the intercostal muscles via the same incision. The incision was closed in a multi-layer fashion. An occlusive dressing was placed over the closure. The case was completed in the standard fashion. The patient was extubated postoperatively without complication and a postoperative CXR was performed and found to be unchanged (Fig. 1). The patient was admitted for observation overnight and placed on supplemental oxygen via nasal cannula to expedite reabsorption. The patient did well postoperatively and did not experience shortness of breath or untoward effect. CXR was obtained 12 h later with no increase or decrease in the size of the pneumothorax (Fig. 1). Patient was discharged home the following morning.
☆ Hypoglossal nerve stimulator complications, unfunded research, departmental support alone. Poster presentation at the Combined Otolaryngology Spring Meeting, The Triological Society, National Harbor, MD, United States. Friday, April 20th–Saturday, April 21st, 2018. ⁎ Corresponding author at: Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA. E-mail address: [email protected] (A.A. Arteaga).
https://doi.org/10.1016/j.amjoto.2018.06.014 Received 11 June 2018 0196-0709/ © 2018 Published by Elsevier Inc.
Please cite this article as: Arteaga, A.A., Am J Otolaryngol (2018), https://doi.org/10.1016/j.amjoto.2018.06.014
Am J Otolaryngol xxx (xxxx) xxx–xxx
A.A. Arteaga et al.
Fig. 1. Chest x-rays from patient obtained immediately post-op (A), and 12 h later (B) showing a small apical pneumothorax (arrows) that did not increase in size between the two time points. Patient remained asymptomatic and was discharged the morning following the procedure.
12 to 24 h of detection or with symptom changes. Patients who display resolution may be discharged home [6]. Asymptomatic patients without PTX progression may also be discharged with follow-up imaging and clinical evaluation 48 h later. If progression of defect or worsening of symptoms, PTX should be evacuated. Large defects in clinically stable patients require drainage using a small-bore catheter (≤14F) or chest tube (16F to 22F) connected to either a Heimlich valve or to a water seal device, and should be hospitalized in most instances [5]. If the lung fails to re-expand quickly, suction should be applied to a water-seal device. Large defects in clinical unstable patients require hospitalization and drainage with chest tube (16F to 22F) or small-bore catheter, depending on the degree of clinical instability. Water seal device can be used without suction initially but should be applied if the lung fails to re-expand with water seal drainage. Tension pneumothorax is a medical emergency that arises as a result of the development of a one-way valve system at the site of the breach in the pleural membrane, permitting air to enter the pleural cavity during inspiration but preventing egress of air during expiration. As a result, an increase in intrapleural pressure that can exceed atmospheric pressure for much of the respiratory cycle can cause impaired venous return and reduced cardiac output causing hypoxemia and hemodynamic compromise. There is usually insufficient time to obtain a chest x-ray. Treatment is with emergency needle decompression (cannula introduced in the second anterior intercostal space in the mid-clavicular line) or chest tube and high concentration oxygen [7]. During the UAS surgical procedure a pocket for the sensing lead is created in the interfascial plane between the internal and external intercostal muscles between the 5th and 6th ribs. A blunt dissection is performed using a thin malleable retractor bent to a miniumum of a right angle at 6 cm from the distal end. The sensor lead is then passed into the pocket underneath the malleable. There are important considerations during this stage of the procedure to avoid producing an iatrogenic PTX. Differences in body habitus (natural curve of the chest wall) need to be considered when choosing and adjusting the angle of the malleable retractor. Different retractors may be used but should be a tapered and blunt-ended, like the Ruggles tapered malleable. Also, attention should be made to lift upwards during blunt dissection to tent up the external intercostal muscle and avoid advancing at an unfavorable angle.
At his postoperative follow up visit, his implant was noted to be working and in proper position. He experienced no further complications and is doing well with his device. 3. Discussion We have presented a unique case of pneumothorax as an intraoperative complication of hypoglossal nerve stimulator surgery. In the initial Stimulation Therapy for Apnea Reduction (STAR) trial, procedure-related adverse events included device-revision, post-op discomfort, temporary tongue weakness, headache, mild infections and other post-op symptoms [2]. Recently the Adherence and Outcome of Upper Airway Stimulation for OSA International Registry (ADHERE) group reported 2 cases of intraoperative bleeding during tunneling of the stimulation lead, 2 cases of seroma [1], but no cases of iatrogenic PTX have been reported. Pneumothorax is defined as the presence of air in the pleural space between the parietal and visceral pleura. This can occur spontaneously with or without underlying lung disease (primary or secondary) or as a result of trauma, including those occurring as a result of medical interventions (iatrogenic) [3]. Clinical signs and symptoms of PTX vary in severity and may include dyspnea, pleuritic chest pain, tachypnea, hypoxia, decreased breath sounds, hyper-resonant percussion and subcutaneous emphysema. Severe signs and symptoms of respiratory distress, tachycardia and hypotension suggest the presence of tension pneumothorax. After initial assessment, imaging is used to confirm the diagnosis. Plain chest radiographs are the most common modality used, but CT scans (used for further evaluation and size quantification), and ultrasound (to confirm diagnosis at the bed side in the settings of trauma patients) are other options available [4]. In our case, signs of pleural space violation were identified during the surgery (rush of air) and were communicated to the anesthesia team. No changes were observed in O2 saturation, tidal volume or intrathoracic pressure. After physical examination, intra-operative chest x-ray was obtained with findings suspicious for pneumothorax and the thoracic surgery team was consult. Based on the size and respiratory stability a decision of proceeding with the surgery was made. The CRX was repeated immediately post-op. CXR showed a small apical pneumothorax. Patient was asymptomatic, was treated with oxygen therapy, and observed overnight. Management course is based on symptoms along with defect size. Pneumothoraces are characterized as large if there is a distance of at least 3 cm from the apex of the lung to the cupula of the chest (American College of Chest Physicians [5]). Small defects (< 20% of the hemithorax) in asymptomatic and hemodynamically stable patients can be safely managed by oxygen supplementation and hospital observation. Imaging can be obtained after
4. Conclusions As mostly head and neck surgeons are performing hypoglossal nerve stimulator placement, management of a pneumothorax often fall out of our level of comfort. Treatment in such cases depends on clinical manifestations and size of the PTX but can be adequately managed 2
Am J Otolaryngol xxx (xxxx) xxx–xxx
A.A. Arteaga et al.
according to the severity with oxygen therapy and observation, needle or cannula aspiration or drainage using small bore catheters or standard chest tubes. We feel that iatrogenic pneumothorax may occur more commonly than previously thought during hypoglossal nerve stimulator surgery. Being able to recognize and treat a PTX is important for surgeons operating near the chest wall.
[2]
[3] [4]
[5]
Disclosures/conflict of interest None.
[6]
References
[7]
[1] Boon M, Huntley C, Steffen A, Maurer JT, Sommer JU, Schwab R, et al. Upper airway stimulation for obstructive sleep apnea: results from the ADHERE Registry.
3
Otolaryngol Neck Surg 2018. http://dx.doi.org/10.1177/0194599818764896. (019459981876489). Strollo PJ, Soose RJ, Maurer JT, de Vries N, Cornelius J, Froymovich O, et al. Upperairway stimulation for obstructive sleep apnea. N Engl J Med 2014;370:139–49. http://dx.doi.org/10.1056/NEJMoa1308659. Feller-Kopman D, Light R. Pleural disease. N Engl J Med 2018;378:740–51. http:// dx.doi.org/10.1056/NEJMra1403503. Ding WM, Shen YM, Yang JM, He XM, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography. Chest 2011;140:859–66. http://dx.doi.org/10. 1378/chest.10-2946. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al. Management of spontaneous pneumothorax. Chest 2001;119:590–602. http://dx.doi.org/10.1378/ chest.119.2.590. Loiselle A, Parish JM, Wilkens JA, Jaroszewski DE. Managing iatrogenic pneumothorax and chest tubes. J Hosp Med 2013;8:402–8. http://dx.doi.org/10.1002/ jhm.2053. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65. http://dx.doi.org/ 10.1136/thx.2010.136986.
Contents lists available at ScienceDirect
Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto
Iatrogenic pneumothorax during hypoglossal nerve stimulator implantation☆ ⁎
Alberto A. Arteaga , Kristen D. Pitts, Andrea F. Lewis Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, Jackson, MS, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Hypoglossal nerve stimulator Obstructive sleep apnea Surgical treatment of obstructive sleep apnea Sleep surgery Iatrogenic pneumothorax
Hypoglossal nerve stimulation is a promising new treatment for patients with obstructive sleep apnea. In the initial Stimulation Therapy for Apnea Reduction Trial, the overall rate of serious adverse events was < 2% and no cases of pneumothorax were reported. We present the case of an iatrogenic pneumothorax during placement of the chest sensor lead between the intercostal muscles. Following clinical and radiological evaluation, surgery was continued and the patient was treated expectantly. In the following review, we discuss pathophysiology, diagnosis, and expected outcomes. Surgeons placing hypoglossal nerve stimulators should be aware of complications and prepared to manage a pneumothorax.
1. Introduction Obstructive sleep apnea is a relatively common sleep disorder characterized by repetitive upper airway collapse during sleep that results in a variety of comorbidities that affect quality of life and cardiovascular risk. Current treatments aim to improve sleep quality and decrease comorbidities associated with OSA. Upper airway stimulation (UAS) therapy is an alternative for patients unable to tolerate first line treatment with continuous positive airway pressure (CPAP) who meet specific severity and phenotypic criteria. UAS therapy has been shown to be a relatively safe procedure with a low incidence of perioperative adverse events [1, 2]. As more cases are being performed, it is important to report unexpected complications in order to refine the surgical technique, prevent reoccurrence of complications as well as to know how to treat them. We present the case of a 52-year-old male who developed an iatrogenic pneumothorax (PTX) during the placement of the chest sensor lead and a brief review of the diagnosis and management or iatrogenic pneumothorax. 2. Case report A 52-year-old male (AHI = 26.9, BMI = 30.24) unable to tolerate CPAP therapy, underwent Inspire® hypoglossal nerve stimulator surgery for treatment of his obstructive sleep apnea. During the creation of the tunnel for chest lead insertion, a rush of air was heard while the
malleable retractor was being advanced between the internal and external intercostal muscles. The retractor was immediately removed and an occlusive dressing, moist gauze and Tegaderm®, was applied to the site. As the patient was being monitored by the Anesthesiologist during the event, the patient never experienced oxygen desaturations or significant changes in tidal volumes or airway pressure. An intraoperative chest x-ray (CXR) was obtained and demonstrated a small pneumothorax. An intraoperative consult was placed to Thoracic surgery. Due to the small nature of the pneumothorax, there was no need for drainage with a pigtail or placement of a chest tube. As it was felt the visceral pleura was not violated and no signs of tension pneumothorax were evidenced, positive pressure ventilation was maintained throughout the procedure. After a discussion with Thoracic surgery, the chest lead was re-inserted in the proper position between the intercostal muscles via the same incision. The incision was closed in a multi-layer fashion. An occlusive dressing was placed over the closure. The case was completed in the standard fashion. The patient was extubated postoperatively without complication and a postoperative CXR was performed and found to be unchanged (Fig. 1). The patient was admitted for observation overnight and placed on supplemental oxygen via nasal cannula to expedite reabsorption. The patient did well postoperatively and did not experience shortness of breath or untoward effect. CXR was obtained 12 h later with no increase or decrease in the size of the pneumothorax (Fig. 1). Patient was discharged home the following morning.
☆ Hypoglossal nerve stimulator complications, unfunded research, departmental support alone. Poster presentation at the Combined Otolaryngology Spring Meeting, The Triological Society, National Harbor, MD, United States. Friday, April 20th–Saturday, April 21st, 2018. ⁎ Corresponding author at: Department of Otolaryngology and Communicative Sciences, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA. E-mail address: [email protected] (A.A. Arteaga).
https://doi.org/10.1016/j.amjoto.2018.06.014 Received 11 June 2018 0196-0709/ © 2018 Published by Elsevier Inc.
Please cite this article as: Arteaga, A.A., Am J Otolaryngol (2018), https://doi.org/10.1016/j.amjoto.2018.06.014
Am J Otolaryngol xxx (xxxx) xxx–xxx
A.A. Arteaga et al.
Fig. 1. Chest x-rays from patient obtained immediately post-op (A), and 12 h later (B) showing a small apical pneumothorax (arrows) that did not increase in size between the two time points. Patient remained asymptomatic and was discharged the morning following the procedure.
12 to 24 h of detection or with symptom changes. Patients who display resolution may be discharged home [6]. Asymptomatic patients without PTX progression may also be discharged with follow-up imaging and clinical evaluation 48 h later. If progression of defect or worsening of symptoms, PTX should be evacuated. Large defects in clinically stable patients require drainage using a small-bore catheter (≤14F) or chest tube (16F to 22F) connected to either a Heimlich valve or to a water seal device, and should be hospitalized in most instances [5]. If the lung fails to re-expand quickly, suction should be applied to a water-seal device. Large defects in clinical unstable patients require hospitalization and drainage with chest tube (16F to 22F) or small-bore catheter, depending on the degree of clinical instability. Water seal device can be used without suction initially but should be applied if the lung fails to re-expand with water seal drainage. Tension pneumothorax is a medical emergency that arises as a result of the development of a one-way valve system at the site of the breach in the pleural membrane, permitting air to enter the pleural cavity during inspiration but preventing egress of air during expiration. As a result, an increase in intrapleural pressure that can exceed atmospheric pressure for much of the respiratory cycle can cause impaired venous return and reduced cardiac output causing hypoxemia and hemodynamic compromise. There is usually insufficient time to obtain a chest x-ray. Treatment is with emergency needle decompression (cannula introduced in the second anterior intercostal space in the mid-clavicular line) or chest tube and high concentration oxygen [7]. During the UAS surgical procedure a pocket for the sensing lead is created in the interfascial plane between the internal and external intercostal muscles between the 5th and 6th ribs. A blunt dissection is performed using a thin malleable retractor bent to a miniumum of a right angle at 6 cm from the distal end. The sensor lead is then passed into the pocket underneath the malleable. There are important considerations during this stage of the procedure to avoid producing an iatrogenic PTX. Differences in body habitus (natural curve of the chest wall) need to be considered when choosing and adjusting the angle of the malleable retractor. Different retractors may be used but should be a tapered and blunt-ended, like the Ruggles tapered malleable. Also, attention should be made to lift upwards during blunt dissection to tent up the external intercostal muscle and avoid advancing at an unfavorable angle.
At his postoperative follow up visit, his implant was noted to be working and in proper position. He experienced no further complications and is doing well with his device. 3. Discussion We have presented a unique case of pneumothorax as an intraoperative complication of hypoglossal nerve stimulator surgery. In the initial Stimulation Therapy for Apnea Reduction (STAR) trial, procedure-related adverse events included device-revision, post-op discomfort, temporary tongue weakness, headache, mild infections and other post-op symptoms [2]. Recently the Adherence and Outcome of Upper Airway Stimulation for OSA International Registry (ADHERE) group reported 2 cases of intraoperative bleeding during tunneling of the stimulation lead, 2 cases of seroma [1], but no cases of iatrogenic PTX have been reported. Pneumothorax is defined as the presence of air in the pleural space between the parietal and visceral pleura. This can occur spontaneously with or without underlying lung disease (primary or secondary) or as a result of trauma, including those occurring as a result of medical interventions (iatrogenic) [3]. Clinical signs and symptoms of PTX vary in severity and may include dyspnea, pleuritic chest pain, tachypnea, hypoxia, decreased breath sounds, hyper-resonant percussion and subcutaneous emphysema. Severe signs and symptoms of respiratory distress, tachycardia and hypotension suggest the presence of tension pneumothorax. After initial assessment, imaging is used to confirm the diagnosis. Plain chest radiographs are the most common modality used, but CT scans (used for further evaluation and size quantification), and ultrasound (to confirm diagnosis at the bed side in the settings of trauma patients) are other options available [4]. In our case, signs of pleural space violation were identified during the surgery (rush of air) and were communicated to the anesthesia team. No changes were observed in O2 saturation, tidal volume or intrathoracic pressure. After physical examination, intra-operative chest x-ray was obtained with findings suspicious for pneumothorax and the thoracic surgery team was consult. Based on the size and respiratory stability a decision of proceeding with the surgery was made. The CRX was repeated immediately post-op. CXR showed a small apical pneumothorax. Patient was asymptomatic, was treated with oxygen therapy, and observed overnight. Management course is based on symptoms along with defect size. Pneumothoraces are characterized as large if there is a distance of at least 3 cm from the apex of the lung to the cupula of the chest (American College of Chest Physicians [5]). Small defects (< 20% of the hemithorax) in asymptomatic and hemodynamically stable patients can be safely managed by oxygen supplementation and hospital observation. Imaging can be obtained after
4. Conclusions As mostly head and neck surgeons are performing hypoglossal nerve stimulator placement, management of a pneumothorax often fall out of our level of comfort. Treatment in such cases depends on clinical manifestations and size of the PTX but can be adequately managed 2
Am J Otolaryngol xxx (xxxx) xxx–xxx
A.A. Arteaga et al.
according to the severity with oxygen therapy and observation, needle or cannula aspiration or drainage using small bore catheters or standard chest tubes. We feel that iatrogenic pneumothorax may occur more commonly than previously thought during hypoglossal nerve stimulator surgery. Being able to recognize and treat a PTX is important for surgeons operating near the chest wall.
[2]
[3] [4]
[5]
Disclosures/conflict of interest None.
[6]
References
[7]
[1] Boon M, Huntley C, Steffen A, Maurer JT, Sommer JU, Schwab R, et al. Upper airway stimulation for obstructive sleep apnea: results from the ADHERE Registry.
3
Otolaryngol Neck Surg 2018. http://dx.doi.org/10.1177/0194599818764896. (019459981876489). Strollo PJ, Soose RJ, Maurer JT, de Vries N, Cornelius J, Froymovich O, et al. Upperairway stimulation for obstructive sleep apnea. N Engl J Med 2014;370:139–49. http://dx.doi.org/10.1056/NEJMoa1308659. Feller-Kopman D, Light R. Pleural disease. N Engl J Med 2018;378:740–51. http:// dx.doi.org/10.1056/NEJMra1403503. Ding WM, Shen YM, Yang JM, He XM, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography. Chest 2011;140:859–66. http://dx.doi.org/10. 1378/chest.10-2946. Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, et al. Management of spontaneous pneumothorax. Chest 2001;119:590–602. http://dx.doi.org/10.1378/ chest.119.2.590. Loiselle A, Parish JM, Wilkens JA, Jaroszewski DE. Managing iatrogenic pneumothorax and chest tubes. J Hosp Med 2013;8:402–8. http://dx.doi.org/10.1002/ jhm.2053. MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65. http://dx.doi.org/ 10.1136/thx.2010.136986.