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POSTOPERATIVE VENTILATORY FAILURE IN A PATIENT WITH PRIMARY ALVEOLAR HYPOVENTILATION
Brit. J. Anaesth. (1973), 45, 11,1
POSTOPERATIVE VENTILATORY FAILURE EN A PATIENT WITH PRIMARY ALVEOLAR HYPOVENTILATION A Case Report S. A. HARGRAVE, J. S. LEGGE AND K. N. V. PALMER SUMMARY
A 50-year-old woman (weight 67 kg, height 1.5 m) was TABLE I. Dynamic and static lung volumes, diffusing admitted as an emergency with a 30-hour history of capacity and blood-gas tensions and pH in a 50-year-old central abdominal pain radiating to the right iliac fossa. female patient with primary alveolar ventilation. On examination she was found to be slightly obese and Pre9 days 3 months pyrexial (38.4°C). There was tenderness and guarding in dicted after after the right iliac fossa. A diagnosis of acute appendicitis was Measurement operation operation normal made and she was given pentazocine 60 mg and prochlorperazine 12.5 mg intramuscularly. Operation was per2.17 1.77 1.78 formed 20 hours after admission, following a period of FEVi (L)(ATPS) observation, and a gangrenous appendix was removed. The FVC (1-XATPS) 2.06 2.15 2.46 anaesthetic was sodium thiopentone 250 mg, suxamethonium 75 mg with endotracheal intubation and controlled FEV(%) 86% 83% 88% ventilation with oxygen, nitrous oxide and halothane. 3.55 3.45 3.60 Muscle relaxation was maintained with alcuronium 10 mg TLC 0-XATPS) and reversed by neostigmine 4 mg with atropine 1.2 mg 1.95 1.75 1.45 injected intravenously. There was some difficulty in estab- FRC (LXATPS) lishing adequate spontaneous respiration immediately after RV(LXATPS) 1.40 1.45 1.25 the operation, but half an hour later her condition was considered satisfactory and she was returned to the ward. RV/TLC(%) 39% 42% 34% The initial postoperative course was uneventful. She DLCO (ml/mm Hg/min) 19.0 15.5 22 received methadone 7.5 mg intramuscularly at 3 and again at 13 hours after the operation. There was no abnormal Pao, (mm Hg) 66.0 71.0 85-100 response to the first dose, as observed clinically. She was first noticed to be drowsy and confused on the following Paooi (mm Hg) 53.0 51.0 35-45 morning, 18 hours after the operation. The arterial oxygen PH tension (Pao,) was 59 mm Hg, the arterial carbon dioxide 7.42 7.45 7.35-7.45 tension (Paoo,) 68 mm Hg and the arterial pH 7.22. Two hours later, and in the absence of specific treatment, her condition had deteriorated further and she became unconscious with Cheyne-Stokes respiration. The Pao, was COMMENT at this stage 32 mm Hg, Paco, 80 mm Hg and pH 7.20. After endotracheal intubation, manual pulmonary ventila- Primary alveolar hypoventilation is seen most comtion was instituted and aminophylline 250 mg, 10% mannitol 200 ml and levallorphan 1.5 mg were injected monly in severely obese patients (Burwell et al., intravenously. Following this, her condition improved 1956). Such patients may develop the so-called rapidly and she regained consciousness. The rest of her Pickwickian syndrome which is characterized by stay in hospital was uneventful. episodes of stupor or even unconsciousness. HowLung function measurements were made 9 days after operation and again 3 months later. The results are shown ever, primary alveolar hypoventilation has also been in table I together with the predicted normal values for a described in the non-obese, where it has usually been woman of her age, height and weight. On both occasions associated with a neurological disorder (Rodman et there was evidence of a mild restrictive ventilatory defect with hypoxaemia and mild hypercapnia. Figure 1 shows al., 1962; Garlind and Linderholm, 1958). In both the ventilatory response to carbon dioxide 3 months after types of patient the main abnormality is thought to operation. It can be seen that the patient showed no increase in ventilation as the end tidal Pco, rose from 55 to 70 mm Hg whereas in 3 normal subjects the ventilation S. A. HARGRAVE, M.B., CH.B.; J. S. LEGGE, M.D.; K. N. V. increased three-fold when the end tidal Pco, rose to these PALMER, M.D., F.R.C.P.; Department of Medicine, Foresterlevels. hill, University of Aberdeen AB9 2ZD.
Downloaded from http://bja.oxfordjournals.org/ at Ryerson University on June 15, 2015
A slightly obese woman developed severe ventilatory failure which required assisted ventilation on the first day after an emergency appendiceaomy. Subsequent investigation revealed a mild restrictive ventilatory defect, hypoxaemia and hypercapnia and an abnormal ventilatory response to carbon dioxide. The patient was considered to have primary alveolar hypoventilation and, because of this, was abnormally sensitive to narcotic analgesics.
BRITISH JOURNAL OF ANAESTHESIA
112
•
NORMAL SUBJECTS
Garlind, T., and Linderholm, H. (1958). Hypoventilation syndrome in a case of chronic epidemic encephalitis. Ada med. scand., 162, 333. Lawrence, L. T. (1959). Idiopathic hypoventilation, polycythaemia and cor pulmonale. Amer. Rev. Resp. Dis., 80, 575. Rodman, T., Resnick, M. E., Berkowitz, R. D., Fennelly, J. F., and Olivia, J. (1962). Alveolar hypoventilation due to involvement of the respiratory centre by obscure disease of the central nervous system. Amer. J. Med., 32, 308.
•
O PATIENT
60
E 40
i
SOMMAIRE
20
u
30
40
50
60
O
70
80
END-TIDAL PCO2
FIG. 1. Carbon dioxide response curves in 3 normal subjects and in a patient with primary alveolar hypoventilation. be a diminished central response to carbon dioxide. Lawrence (1959), however, described a patient with idiopathic alveolar hypoventilation who weighed only 167 lb. He had polycythaemia and cor pulmonale, but at post-mortem examination, no lesions of the brain or lungs was demonstrated. The patient described here was slightly overweight but could not be considered obese. There was no clinical evidence of neurological disease so that she appears to have primary alveolar hypoventilation of unknown cause. The episode of severe ventilatory failure after operation was probably brought about by the administration of narcotic analgesics to a patient who was not, at that time, known to have a markedly diminished ventilatory response to carbon dioxide. This concept is supported by the rapid return of consciousness and adequate ventilation following the administration cf a morphine antagonist and respiratory stimulants. REFERENCES
Burwell, C. S., Robin, E. D., Whaky, R. D., and Bickelmann, A. G. (1956). Extreme obesity associated with alveolar hypoventilation: a Pickwickian syndrome. Amcr. J. Med.. 21.811.
Une femme legerement obese a developp* une insuffisance seVere de la ventilation, qui a necissiti la respiration assisted le premier jour apres une appendectomie d'urgence. L'^tude consecutive a i&viH l'existence d'un leger defaut restricteur de la ventilation, de l'hypoxemie et hypercapnie et une reaction ventilatrice abnormale a l'anhydride carbonique. La malade a iti conside'ree presenter une hypoventilation alveolaire primaire, et pour cette raison fitre abnormalement sensible aux analgesiques narcotiques.
POSTOPERATIVES VERSAGEN DER ATMUNG BEI EINEM PATIENTEN MIT PRIMARER ALVEOLARER HYPOVENTILATION: KASUISTISCHE MITTEILTJNG ZUSAMMENFASSUNG
Bei einer etwas adiposen Frau stellte sich am ersten postoperativen Tage nach einer dringlichen Appendektomie cine schwere Atmungsinsuffizienz ein, welche assistierte Btatmung erforderlich machte. Die nachfolgenden Untersuchungtn ergaben einen maOigen restriktiven. ventilatorischen Defekt, Hypoxaemie und Hyperkapnie, ferner cine atypische ventilatorische Reaktion auf Kohlendioxyd. Es war anzunehmen, daO bei der Patientin eine prim^re alveolare Hypoventilation vorlag und dafl si: deswegen auBergewdhniich empfindlich auf Narko-Analgetica reagierte.
INSUFICIENCIA VENTILATORIA POSTOPERATORIA EN UNA PACIENTE CON HIPOVENTILACION ALVEOLAR PRIMARIA: COMUNICACION DE UN CASO RESUMEN
Una mujer ligeramente obesa desarroll6 una intensa insuficiencia ventilatoria que requiri6 una ventilaci6n asistida durante el primer dfa despues de una apendicectomfa de urgencia. Una investigaci6n subsiguiente reve!6 un ligero defecto ventilatorio restrictivo, hipoxemia e hipercapnia con una respuesta ventilatoria anormal al anhfdrido carbonico. Se consider6 que la paciente tenfa una hipovenrilaci6n alveolar primaria y, a causa de ello, era anormalmente sensible a los analgesicos narc6ticos.
Downloaded from http://bja.oxfordjournals.org/ at Ryerson University on June 15, 2015
INSUFFISANCE POST-OPERATOIRE DE LA VENTILATION CHEZ UN PATIENT AVEC UNE HYPOVENTILATION ALVEOLAIRE PRIMAIRE: DESCRIPTION LVUN CAS
POSTOPERATIVE VENTILATORY FAILURE EN A PATIENT WITH PRIMARY ALVEOLAR HYPOVENTILATION A Case Report S. A. HARGRAVE, J. S. LEGGE AND K. N. V. PALMER SUMMARY
A 50-year-old woman (weight 67 kg, height 1.5 m) was TABLE I. Dynamic and static lung volumes, diffusing admitted as an emergency with a 30-hour history of capacity and blood-gas tensions and pH in a 50-year-old central abdominal pain radiating to the right iliac fossa. female patient with primary alveolar ventilation. On examination she was found to be slightly obese and Pre9 days 3 months pyrexial (38.4°C). There was tenderness and guarding in dicted after after the right iliac fossa. A diagnosis of acute appendicitis was Measurement operation operation normal made and she was given pentazocine 60 mg and prochlorperazine 12.5 mg intramuscularly. Operation was per2.17 1.77 1.78 formed 20 hours after admission, following a period of FEVi (L)(ATPS) observation, and a gangrenous appendix was removed. The FVC (1-XATPS) 2.06 2.15 2.46 anaesthetic was sodium thiopentone 250 mg, suxamethonium 75 mg with endotracheal intubation and controlled FEV(%) 86% 83% 88% ventilation with oxygen, nitrous oxide and halothane. 3.55 3.45 3.60 Muscle relaxation was maintained with alcuronium 10 mg TLC 0-XATPS) and reversed by neostigmine 4 mg with atropine 1.2 mg 1.95 1.75 1.45 injected intravenously. There was some difficulty in estab- FRC (LXATPS) lishing adequate spontaneous respiration immediately after RV(LXATPS) 1.40 1.45 1.25 the operation, but half an hour later her condition was considered satisfactory and she was returned to the ward. RV/TLC(%) 39% 42% 34% The initial postoperative course was uneventful. She DLCO (ml/mm Hg/min) 19.0 15.5 22 received methadone 7.5 mg intramuscularly at 3 and again at 13 hours after the operation. There was no abnormal Pao, (mm Hg) 66.0 71.0 85-100 response to the first dose, as observed clinically. She was first noticed to be drowsy and confused on the following Paooi (mm Hg) 53.0 51.0 35-45 morning, 18 hours after the operation. The arterial oxygen PH tension (Pao,) was 59 mm Hg, the arterial carbon dioxide 7.42 7.45 7.35-7.45 tension (Paoo,) 68 mm Hg and the arterial pH 7.22. Two hours later, and in the absence of specific treatment, her condition had deteriorated further and she became unconscious with Cheyne-Stokes respiration. The Pao, was COMMENT at this stage 32 mm Hg, Paco, 80 mm Hg and pH 7.20. After endotracheal intubation, manual pulmonary ventila- Primary alveolar hypoventilation is seen most comtion was instituted and aminophylline 250 mg, 10% mannitol 200 ml and levallorphan 1.5 mg were injected monly in severely obese patients (Burwell et al., intravenously. Following this, her condition improved 1956). Such patients may develop the so-called rapidly and she regained consciousness. The rest of her Pickwickian syndrome which is characterized by stay in hospital was uneventful. episodes of stupor or even unconsciousness. HowLung function measurements were made 9 days after operation and again 3 months later. The results are shown ever, primary alveolar hypoventilation has also been in table I together with the predicted normal values for a described in the non-obese, where it has usually been woman of her age, height and weight. On both occasions associated with a neurological disorder (Rodman et there was evidence of a mild restrictive ventilatory defect with hypoxaemia and mild hypercapnia. Figure 1 shows al., 1962; Garlind and Linderholm, 1958). In both the ventilatory response to carbon dioxide 3 months after types of patient the main abnormality is thought to operation. It can be seen that the patient showed no increase in ventilation as the end tidal Pco, rose from 55 to 70 mm Hg whereas in 3 normal subjects the ventilation S. A. HARGRAVE, M.B., CH.B.; J. S. LEGGE, M.D.; K. N. V. increased three-fold when the end tidal Pco, rose to these PALMER, M.D., F.R.C.P.; Department of Medicine, Foresterlevels. hill, University of Aberdeen AB9 2ZD.
Downloaded from http://bja.oxfordjournals.org/ at Ryerson University on June 15, 2015
A slightly obese woman developed severe ventilatory failure which required assisted ventilation on the first day after an emergency appendiceaomy. Subsequent investigation revealed a mild restrictive ventilatory defect, hypoxaemia and hypercapnia and an abnormal ventilatory response to carbon dioxide. The patient was considered to have primary alveolar hypoventilation and, because of this, was abnormally sensitive to narcotic analgesics.
BRITISH JOURNAL OF ANAESTHESIA
112
•
NORMAL SUBJECTS
Garlind, T., and Linderholm, H. (1958). Hypoventilation syndrome in a case of chronic epidemic encephalitis. Ada med. scand., 162, 333. Lawrence, L. T. (1959). Idiopathic hypoventilation, polycythaemia and cor pulmonale. Amer. Rev. Resp. Dis., 80, 575. Rodman, T., Resnick, M. E., Berkowitz, R. D., Fennelly, J. F., and Olivia, J. (1962). Alveolar hypoventilation due to involvement of the respiratory centre by obscure disease of the central nervous system. Amer. J. Med., 32, 308.
•
O PATIENT
60
E 40
i
SOMMAIRE
20
u
30
40
50
60
O
70
80
END-TIDAL PCO2
FIG. 1. Carbon dioxide response curves in 3 normal subjects and in a patient with primary alveolar hypoventilation. be a diminished central response to carbon dioxide. Lawrence (1959), however, described a patient with idiopathic alveolar hypoventilation who weighed only 167 lb. He had polycythaemia and cor pulmonale, but at post-mortem examination, no lesions of the brain or lungs was demonstrated. The patient described here was slightly overweight but could not be considered obese. There was no clinical evidence of neurological disease so that she appears to have primary alveolar hypoventilation of unknown cause. The episode of severe ventilatory failure after operation was probably brought about by the administration of narcotic analgesics to a patient who was not, at that time, known to have a markedly diminished ventilatory response to carbon dioxide. This concept is supported by the rapid return of consciousness and adequate ventilation following the administration cf a morphine antagonist and respiratory stimulants. REFERENCES
Burwell, C. S., Robin, E. D., Whaky, R. D., and Bickelmann, A. G. (1956). Extreme obesity associated with alveolar hypoventilation: a Pickwickian syndrome. Amcr. J. Med.. 21.811.
Une femme legerement obese a developp* une insuffisance seVere de la ventilation, qui a necissiti la respiration assisted le premier jour apres une appendectomie d'urgence. L'^tude consecutive a i&viH l'existence d'un leger defaut restricteur de la ventilation, de l'hypoxemie et hypercapnie et une reaction ventilatrice abnormale a l'anhydride carbonique. La malade a iti conside'ree presenter une hypoventilation alveolaire primaire, et pour cette raison fitre abnormalement sensible aux analgesiques narcotiques.
POSTOPERATIVES VERSAGEN DER ATMUNG BEI EINEM PATIENTEN MIT PRIMARER ALVEOLARER HYPOVENTILATION: KASUISTISCHE MITTEILTJNG ZUSAMMENFASSUNG
Bei einer etwas adiposen Frau stellte sich am ersten postoperativen Tage nach einer dringlichen Appendektomie cine schwere Atmungsinsuffizienz ein, welche assistierte Btatmung erforderlich machte. Die nachfolgenden Untersuchungtn ergaben einen maOigen restriktiven. ventilatorischen Defekt, Hypoxaemie und Hyperkapnie, ferner cine atypische ventilatorische Reaktion auf Kohlendioxyd. Es war anzunehmen, daO bei der Patientin eine prim^re alveolare Hypoventilation vorlag und dafl si: deswegen auBergewdhniich empfindlich auf Narko-Analgetica reagierte.
INSUFICIENCIA VENTILATORIA POSTOPERATORIA EN UNA PACIENTE CON HIPOVENTILACION ALVEOLAR PRIMARIA: COMUNICACION DE UN CASO RESUMEN
Una mujer ligeramente obesa desarroll6 una intensa insuficiencia ventilatoria que requiri6 una ventilaci6n asistida durante el primer dfa despues de una apendicectomfa de urgencia. Una investigaci6n subsiguiente reve!6 un ligero defecto ventilatorio restrictivo, hipoxemia e hipercapnia con una respuesta ventilatoria anormal al anhfdrido carbonico. Se consider6 que la paciente tenfa una hipovenrilaci6n alveolar primaria y, a causa de ello, era anormalmente sensible a los analgesicos narc6ticos.
Downloaded from http://bja.oxfordjournals.org/ at Ryerson University on June 15, 2015
INSUFFISANCE POST-OPERATOIRE DE LA VENTILATION CHEZ UN PATIENT AVEC UNE HYPOVENTILATION ALVEOLAIRE PRIMAIRE: DESCRIPTION LVUN CAS