Beruflich Dokumente
Kultur Dokumente
C ASE R EPORT
Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School,
Gwangju, South Korea.
2
Department of Radiology, Chonnam National University Medical School, Gwangju, South Korea.
3
Department of Physiology, Chonnam National University Medical School, Gwangju, South Korea.
1. Introduction
2. Case Report
*Corresponding author. Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School,
8 Hak-dong, Gwangju 501-190, South Korea.
E-mail: kyyoo@jnu.ac.kr
2009 Taiwan Society of Anesthesiologists
213
Figure 1 Chest radiograph immediately after endotracheal intubation showing collapse of the right upper lobe at
first (A) and second (B) attempts of anesthesia for surgery of moyamoya disease.
214
mechanical ventilation. Fiberoptic bronchoscopy
showed that the trachea and bronchial tree were
free from obstruction. The surgery was called off,
and the residual neuromuscular block was reversed.
The patient was transported to the recovery room,
and a follow-up chest X-ray revealed nothing of
note. Chest computed tomography taken 2 days
afterwards showed no anatomic anomalies of the
tracheobronchial tree (e.g., tracheal bronchus)8 or
extraluminal mass. Neither the methacholine and
histamine bronchial provocation test, nor the skin
test for propofol, fentanyl and rocuronium performed 3 days after the second episode of atelectasis showed positive findings.
3. Discussion
It is generally agreed that atelectasis is caused by
obstruction of a bronchus (either because of massive secretion, aspiration, encroachment of a foreign body or intrabronchial intubation) followed by
rapid absorption of the trapped alveolar gas. In our
case, however, right main and upper lobe bronchi
were free from obstruction on fiberoptic bronchoscopy. A stimulus that increases vagal tone is known
to play an important role in triggering bronchial
obstruction, resulting in reflex atelectasis, which
is characterized by fast onset, absence of intrabronchial obstruction, and signs of parasympathetic
stimulation.57 Mechanical stimulation of the laryngeal mucosa has been demonstrated to reflexively
enhance vagal activity, irritating the trachea and
bronchi and increasing total lung resistance.9 Acute
RUL atelectasis was likely to have been associated
with the vagally-induced airway reflex in our case,
as manifested by acute onset of bronchospasm in
the absence of intrabronchial obstruction.
Interestingly, the patient did not show any signs
of acute bronchoconstriction during anesthetic induction for laparoscopic cholecystectomy in the
previous surgery, performed 4 months before. At
that time, anesthesia was induced with thiopental
sodium 375 mg and succinylcholine 80 mg, and
maintained with sevoflurane 23% and 50% N2O in
oxygen and vecuronium, while the two consecutive anesthesias were induced with propofol, fentanyl and rocuronium.
Unlike thiopental, propofol may decrease respiratory resistance and hence could prevent bronchospasm resulting from airway instrumentation.10
Moreover, propofol has been demonstrated to
significantly inhibit vagally-induced bronchoconstriction.11 Nevertheless, propofol is responsible
for perioperative anaphylactic shock in France in
1.2% of cases.12 Previous investigators have documented that propofol could cause bronchospam.1315
K.Y. Yoo et al
Although exceedingly rare, allergic reactions to
fentanyl, IntralipidTM and rocuronium have also
been described.12,16 Thus, drug (propofol, fentanyl,
or rocuronium)-induced bronchospasm may have
played a role in inducing intraoperative respiratory
difficulties. However, the absence of a severe
hypotensive episode and generalized erythema at
the onset of the wheezing would argue against
drug-induced histamine release as a priming event
in our case. In addition, the patient did not show
any signs of adverse reactions immediately after the
intravenous administration of those drugs before
the intubation. Moreover, neither the methacholine
and histamine bronchial provocation test, nor the
skin test for propofol, fentanyl and rocuronium
performed a few days thereafter were positive.
A bronchospasm without anaphylactoid reaction
after propofol administration has been reported in
a patient with sick house syndrome.17 In this case,
the drug lymphocyte stimulation test showed a positive reaction against propofol although a skin test
was negative, suggesting that propofol could be
responsible for the bronchospasm during the induction of anesthesia. It is suggested that bronchial
hypersensitivity may trigger bronchospasm in response to a sensitizing drug. Angiotensin-converting
enzyme inhibitors have also been demonstrated to
enhance bronchial responsiveness especially in
smokers.1820 As our patient was a smoker taking
irbesartan, we could not rule out the possibility that
irbesartan could be responsible for enhancing the
bronchospasm induced by propofol.
Although the underlying mechanisms are unclear, most acute lobar collapses associated with
bronchospasm after anesthesia induction developed selectively in RUL.3,5,7 It has been postulated
that the relatively straight, right mainstem bronchus and an almost 90 take-off of the RUL bronchus
may create a favorable condition for the Bernoulli
effect around the opening of RUL bronchus.21
Sprung et al7 suggested that this effect should be conspicuous when the lungs are vigorously ventilated,
because of increased resistance (bronchospasm),
causing rapid laminar air flow to be preferentially
directed toward the right lower and middle lobes,
bypassing the RUL bronchus, quickly drawing gas
out of the RUL and causing acute lobar collapse.
It may be difficult to decide whether the scheduled surgery should be carried out or not if the
patient develops reflex atelectasis. The operation
for moyamoya disease may be of long duration, and
it requires tight control of arterial carbon dioxide
tension during surgery. Therefore, under such circumstances, we postponed the surgery for our patient. In most reported cases, however, the scheduled
surgeries proceeded uneventfully without recurrence or aggravation, since the atelectasis resolved
215
9.
10.
11.
12.
13.
14.
References
1.
2.
3.
4.
5.
6.
7.
8.
15.
16.
17.
18.
19.
20.
21.