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SPA Newsletter

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Volume 17 Number 3
Summer 2004 Newsletter
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Unilateral negative-pressure pulmonary edema in an infant during bronchoscopy

Shai Hannania, MD, et al. Pediatrics 2004;113:e501-e503. URL: http://www.pediatrics.org/cgi/content/full/113/5/e501

This is a report of a single case of a complication during flexible bronchoscopy in an infant. The patient was anesthetized with incremental inhaled halothane and oxygen. Spontaneous respiratory effort ".with the assistance of intermittent bag ventilation" was maintained. The report does mention the administration of ".small boluses' of Propofol whenever the patient reacted to airway manipulation, presumably the bronchoscope. There is no mention of the use of any airway devices by the anesthesiologist. The bronchoscopist used a 3.5 mm video-assisted bronchoscope, presumably inserted directly into the trachea. After wedging the tip of the scope in to the right bronchus, bronchoalveolar lavage was performed, using 5 cc saline with the suction port of the bronchoscope connected via the standard bottle system to wall suction. The setting on the suction is not noted. The lavage fluid collected after the initial instillation was hazy. The oximeter reading immediately dropped to the mid 70's and the child's respirations became irregular. The oxygen saturation did not improve with assisted bag ventilation using 100% oxygen. The child was then intubated using a 3.5 mm OETT and over the next 15-20 minutes, the saturation improved to 94-97%. A CXR showed patchy infiltrates suggestive of right-sided pulmonary edema. These are included in the published report. The infant was successfully extubated six hours later.

The authors speculate that the act of suctioning the lavage fluid with excessive negative pressure is the likely cause of the pulmonary edema but do not rule out the possibility that the child herself may have generated the negative pressure during the procedure, even though this form of negative pressure pulmonary edema is generally seen in larger patients who inspire against a closed glottis.

Commentary

This case report is illustrative of the difficulties possible with airway manipulation, particularly in infants. There is not a completely satisfactory management for small infants undergoing diagnostic bronchoscopy. If the anesthesiologist intubates the patient, following induction the bronchoscopist is limited to a very small scope, one without suction capability. If, one the other hand the airway is left unprotected during the procedure, positive pressure cannot be given and it is very difficult to maintain anesthesia with intravenous agents. An LMA offers some advantages. A larger bronchoscope can pass through the LMA opening than can pass through an endotracheal tube and there is some ability for the anesthesiologist to administer vapor anesthetics as well as positive pressure when needed. If this technique is chosen, it may be prudent to intubate the child at the conclusion of the procedure.

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