SPA 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.

Table of Contents

• Editor's Corner
• President's Message
• Society for Pediatric Anesthesia Policy Statment on Provision of Pediatric Anesthesia Care
• Williams Syndrome, Supravalvar Aortic Stenosis and Cardiac Arrest During Anesthesia
• Book Corner
• Out of Africa
• Peds Passport
• MHAUS Research Opportunities
• For Patients: Frequently Asked Questions


• Reviews & Commentary
  • Bariatric surgery for severely overweight adolescents: concerns and recommendations.
    Inge T, et al. Pediatrics 2004;114;217-223
  • Conscious sedation of children with propofol is anything but conscious
    Reeves ST, Havidich JE, and Tobin DP. Pediatrics 2004;114:e74-e76. URL http://www.pediatrics.org/cgi/content/ full/114/1/e74
  • A factorial trial of six interventions for the prevention of postoperative nausea and vomiting.
    Apfel CC, et al. N Engl J Med 2004; 50:2441-2451
  • The effect of dexrazoxane of myocardial injury in dozorubicin-treated children with acute lymphoblastic leukemia
    Lipshultz SE, et al. N Engl J Med 2004; 351:145-153
  • 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
  • Does pediatric surgical specialty training affect outcome after Ramstedt Pyloromyotomy? A population-based study.
    Langer J, To T. Pediatrics 2004;113:1342-1347
  • Overweight children and adolescents; A risk group for iron deficiency
    Nead KG, et al. Pediatrics 2004;114:104-108
  • A comparison of conservative and aggressive transfusion regimens in the perioperative management of sickle cell disease
    Elliot P. Vichinsky, MD, et al and the Preoperative Transfusion in Sickle Cell Disease Study Group
  • Cholecystectomy in sickle cell anemia patients: Perioperative outcome of 364 cases from the National Preoperative Transfusion Study
    Charles M. Haberkern, et al, and the Preoperative Transfusion in Sickle Cell Disease Study Group
  • Effect of hydroxyurea on the frequency of painful crises in sickle cell anemia
    Samuel Charache, MD, et al
  • Epidural Analgesia in the Management of Severe Vaso-Occlusive Sickle-Cell Crisis.
    Yaster M, et al. Pediatrics 1994;93:310-315


• Literature Reviews
  • A case of propofol toxicity: further evidence for a causal mechanism
    Davinia E Withington, Mary K. Decell, Tareq Al Ayed. Pediatric Anesthesia 2004;14:505
    Death after re-exposure to propofol in a 3-year-old child: a case report
    Josef Holzki, Christoph Aring, Alex Gillor. Paediatric Anaesthesia 2004;14:265
  • Does anaesthesia harm the developing brain - evidence or speculation?
    Andrew Davidson and Sulpicio Soriano. Paediatric Anaesthesia 2004; 14: 199-20.
  • An evaluation of pediatric in-hospital advanced life support interventions using the pediatric Utstein guidelines: a review of 203 cardiorespiratory arrests.
    J. Guay, L. Lortie.Can J Anesth 2004:51:4:373-378
  • A factorial trial of six interventions for the prevention of postoperative nausea and vomiting
    Christian C. Apfel, MD, et al. IMPACT Investigators. N Engl J Med 2004;350:2441-51
  • Interactive Music Therapy as a Treatment for Preoperative Anxiety in Children: A Randomized Controlled Trial
    Kain Z, Caldwell-Andrews A, Krivutza D, Weinberg M, Gaal D, Wang SM, Mayes L. Anesthesia & Analgesia 2004;98:1260-1266.
  • Trends in the practice of parental presence during induction of anesthesia and the use of preoperative sedative premedication in the United States, 1995-2002: results of a follow-up national survey.
    Kain, Z.N. et al. Anesth Analg 2004; 98:1252-9.
  • Anesthetic Complications of Tympanostomy Tube Placement in Children.
    Hoffmann KK, Thompson GK, Burke BL et al. Arch Otolaryngol Head Neck Surg. 128:1040-1043, 2002
  • Neurobehavioral Implications of Habitual Snoring in Children.
    O'Brien CM, et al. Pediatrics 2004; 116:44-50

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