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2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Severe Bronchospasm and Desaturation in a Child Associated with THE use of rapacuronium has been associated with oc- elapsed since her initial intubation. At this point, she also was noted to casional episodes of self-limited increased airway pres- have truncal erythema and an O saturation of 70%. She was given four doses of 100 ␮g albuterol aerosol via the endotracheal tube, and sure with or without mild oxygen (O ) desaturation and ventilation was attempted again with 8% sevoflurane in O . During the wheezing. To our knowledge, this is the first report of next minute, it became possible to ventilate with small tidal volumes severe bronchospasm associated with a transient inabil- and ventilating pressures between 20 and 30 cm H O. O saturations began to increase, and wheezing breath sounds could now be heard. A treatment of 2.5 mg nebulized albuterol was administered via theendotracheal tube, and 50 mg benadryl was administered intrave-nously. During the ensuing 5 min, manual ventilation became progres- Case Report
sively easier with tidal volumes increasing to 350 – 450 ml at pressuresof 15–20 cm H O. The patient’s O breath sounds returned to normal, and the erythema dissipated. During The patient was a 10-yr-old girl who was brought to the operating this event, her blood pressure had ranged between 90/60 and 110/50 room to undergo appendectomy. Except for 1 week of abdominal pain mmHg, and her pulse had ranged between 90 and 115 beats/min.
and mild nausea but no vomiting, her history was negative. There were Anesthesia was continued with 2– 4% sevoflurane, 2 l/min O , and no previous anesthetics, environmental or drug allergies, recent upper 2 l/min N O. Rocuronium, 10 mg, was required to assist with relax- respiratory infection, or reactive airway disease. No one in her house- ation. Surgery proceeded uneventfully with the removal of an inflamed hold smoked. She weighed 62 kg and was 138 cm tall. Except for retrocecal appendix. Muscle relaxation was reversed with 1 mg findings related to her surgical problem, her physical examination was neostigmine and 0.2 mg glycopyrrolate. With the patient spontane- unremarkable, and her chest was clear.
ously breathing, volumes of 250 – 400 ml at a respiratory rate of 20 While the patient was preoxygenated for 3 min using a 6-l/min flow breaths/min, and an equal train-of-four, nitrous oxide was discontin- of O , the usual monitors were applied. Then, 1 mg midazolam and ued. We elected to extubate the patient deeply, so after 5 min of 4% 50 ␮g fentanyl were administered intravenously. After an additional sevoflurane in O , the stomach and oropharynx were thoroughly 2 min of oxygen administration, a rapid sequence induction was suctioned, and the endotracheal tube was removed. She continued to performed with 150 mg propofol, immediately followed by 100 mg breathe 100% O spontaneously, awoke, and was transferred to the intravenous rapacuronium (approximately 1.6 mg/kg). After 30 s, O postanesthesia care unit, where her O saturation with room air was saturation was noted to decrease from 100% to approximately 95%. We 99 –100% and her chest was clear. Chest radiography results were elected to administer ventilation by mask for an additional 45 s with negative. She was transferred to the pediatric unit and was discharged while applying cricoid pressure. Her chest rose, but O saturation improved only slightly to 96%. A cuffed No. 6.5 endotrachealtube was placed in her trachea with apparent ease, followed by animmediate attempt at manual ventilation. Despite ventilating pressuresof up to 30 cm H O, breath sounds, chest movement, endotracheal Discussion
tube fogging, end-tidal carbon dioxide, or gastric sounds could not bedetected. The anesthesia circuit was rechecked quickly and was ob- This patient had no factors predisposing her to a reac- served to be patent. While maintaining cricoid pressure, the endotra-cheal tube was removed and noted to be unobstructed, and an attempt tive airway. Of the anesthetics used for induction, mida- was made at bag and mask ventilation. Unlike with the preintubation zolam, fentanyl, and propofol usually are not associated mask ventilation, this time, there were no chest movements, breath with bronchospasm. Increased airway pressure with or sounds, or end-tidal carbon dioxide. The patient was reintubated eas- ily, but ventilation remained impossible. Approximately 2 min had ported in clinical studies of rapacuronium. The manufac-turer’s package insert reports an incidence of 3.2%, withno data about the severity. Kahwaji et al.1 reported This article is accompanied by an Editorial View. Please see:Goudsouzian NG: Rapacuronium and bronchospasm. ANESTHE- bronchospasm and erythema that developed in an Amer- ican Society of Anesthesiologists class I patient 30 s after2 mg/kg rapacuronium and gradually subsided after sal-butamol. Mild wheezing developed in a second patient * Attending Anesthesiologist, Anesthesia Department, New Britain General after a dose of 1 mg/kg. These authors suggest that Hospital, and Clinical Assistant and Professor of Anesthesiology, Department ofAnesthesiology, histamine release is responsible. Fleming et al.2 studied 336 patients; half were intubated with 1 mg/kg succinyl- Received from New Britain General Hospital, New Britain, Connecticut. Submit- choline, and half were intubated with 1.5 mg/kg rapa- ted for publication May 15, 2000. Accepted for publication November 30, 2000.
Support was provided solely from institutional and/or departmental sources.
curonium. Bronchospasm, defined as wheezing, oc- Address reprint requests to Dr. Kron: New Britain General Hospital, 100 Grand curred in five of the rapacuronium patients, as opposed to only two of the succinylcholine patients. All but one skmel@aol.com or sskron@netscape.net. Individual article reprints may be pur-chased through the Journal Web site, www.anesthesiology.org.
of these patients had factors predisposing to broncho- spasm, and six cases were mild and were resolved with tory dysfunction developed after intubation, O satura- minimal or no therapy. One patient in the rapacuronium tion unexpectedly decreased 30 s after rapacuronium group had bronchospasm of “moderate severity” that administration and before airway instrumentation. The required subsequent doses of ␤ agonist and intravenous patient had been preoxygenated thoroughly, so it is probable that the initial decrease in O saturation was In a similar study, Sparr et al.3 found 4 cases of in- secondary to the evolving bronchospasm.
creased airway pressure and 14 cases of bronchospasm In summary, a case of rapacuronium-associated severe among the 168 patients intubated with 1.5 mg/kg rapa- bronchospasm and O desaturation in a child with no curonium. This incidence of 10.7% pulmonary side ef- predisposing factors is presented. Fortunately, the pa- fects was compared with 4.1% of 167 patients intubated tient responded quickly and well to ␤-adrenergic therapy with succinylcholine. One of the rapacuronium patients, and deepening anesthesia and was free of symptoms by who had a previous history of chronic bronchitis, was noted to have had “a serious adverse experience.” Afterintubation, bronchospasm developed in the patient, andO saturation decreased to 88% before improvement References
with bronchodilators. An accompanying editorial4 suggeststhat histamine or leukotriene release may be responsible 1. Kahwaji R, Bevan DR, Bikhazi G, Shanks C, Fragen R, Dyck B, Angst M, but noted that this remains to be proven. Levy et al.5 Matteo R: Dose-ranging study in younger adult and elderly patients of Org 9487,a new rapid-onset, short duration muscle relaxant. Anesth Analg 1997; 84: described bronchospasm in 7 of 47 patients to whom 1–3 mg/kg rapacuronium was administered but note that in 2. Fleming NW, Chung F, Glass PS, Kitts J, Kirkegaard-Nielsen H, Gronert G, Chan V, Gan T, Cicutti N, Caldwell J: Comparison of the intubating conditions some of these patients there may have been other provok- provided by rapacuronium (ORG 9487) or succinylcholine in humans during ing factors. Interestingly, histamine concentrations were anesthesia with fentanyl and propofol. ANESTHESIOLOGY 1999; 91:1311–7 3. Sparr HJ, Mellinghoff H, Blobner M, Noldge-Schomburg G: Comparison of measured in this study and noted to increase to more intubating conditions after rapacuronium (Org 9487) and succinylcholine follow- than 1 ng/ml in five patients, but none of these patients ing rapid sequence induction in adult patients. Br J Anaesth 1999; 82:537– 41 4. Goulde MR, Hunter JM: Rapacuronium (Org 9487): Do we have a replace- experienced bronchospasm or erythema, suggesting that ment for succinylcholine? (editorial). Br J Anaesth 1999; 82:489 –91 histamine is not the cause of the pulmonary problem.
5. Levy JH, Pitts M, Thanopoulos A, Szlam F, Bastian R, Kim J: The effects of rapacuronium on histamine release and hemodynamics in adult patients under- In the current patient, although more severe ventila- going general anesthesia. Anesth Analg 1999; 89:290 –5 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
How Serious Is the Bronchospasm Induced by Rapacuronium? Mohamed Naguib, M.B., B.Ch., M.Sc., F.F.A.R.C.S.I., M.D.* RAPACURONIUM (16-N-allyl, 17-␤-propionate analog of Case Report
vecuronium) is a new rapid-onset, short-acting, nonde-polarizing steroidal neuromuscular blocking drug. Con- A 34-yr-old woman, American Society of Anesthesiologists class I, cern has been raised with respect to possible respiratory who weighed 90 kg and was 173.5 cm tall was scheduled to undergolaparoscopic tubal ligation. Her medical history was not significant, effects of rapacuronium. The following case report de- except for hepatitis B at the age of 13 yr and a history of depressive scribes a patient in whom severe bronchospasm devel- disorder. The patient was not taking medication. She was a smoker (10 oped after rapacuronium administration.
cigarettes per day). Examination was unremarkable. Routine monitor-ing was used. The patient was preoxygenated, achieving an oxygensaturation measured by pulse oximetry (SpO ) of 100%. Anesthesia was This article is accompanied by an Editorial View. Please see: induced with 1 mg midazolam, 150 ␮g fentanyl, and 200 mg propofol, Goudsouzian NG: Rapacuronium and bronchospasm. ANESTHE- followed immediately by 1.4 mg/kg rapacuronium. Anesthesia was maintained immediately with 4% inspired desflurane in oxygen. Oneminute after administration of rapacuronium, intubation was achievedeasily. Severe bronchospasm (wheezing, increased airway pressureduring positive pressure ventilation [peak inspiratory pressure of 45 cm H O], and prolonged expiratory phase) occurred just after Received from the Department of Anesthesia, University of Iowa College of tracheal intubation. Positive pressure ventilation became exceedingly Medicine, Iowa City, Iowa. Submitted for publication July 13, 2000. Accepted for difficult. Inhalational bronchodilator (albuterol) therapy was adminis- publication July 19, 2000. Support was provided solely from institutional and/ordepartmental sources. Dr. Naguib has received research grants sponsored by tered via an AeroVent® Collapsible Holding Chamber (Monaghan Med- Burroughs Wellcome Company, United Kingdom, and Organon, Inc., West Or- ical Corp., Plattsbrug, NY) attached to the inspiratory limb of the anesthetic circuit. SpO decreased to 85% despite the administration of Address reprint requests to Dr. Naguib: University of Iowa College of Medi- 100% oxygen, and PETCO was 47 mmHg. This lasted for 7 min. The cine, Department of Anesthesia, 200 Hawkins Drive, 6JCP, Iowa City, Iowa clinical picture gradually improved afterward, and SpO 52242-1009. Address electronic mail to: mohamed-naguib@uiowa.edu. Individual slowly to 92%. Approximately 15 min after rapacuronium administra- tion, the wheezing resolved, the peak inspiratory pressure decreased increased to 96%. The content of one albuterol release.3 The affinity of neuromuscular blockers for the nebulizer was administered during this event. Each actuation administers muscarinic receptor seems to have some influence on 90 ␮g albuterol. After this event, anesthesia was maintained with 60% neural control of airway caliber. Pancuronium and atra- nitrous oxide and desflurane (end-tidal concentration, 2.6 –3.0%) in oxy-gen. Neuromuscular block was maintained with 0.2 mg/kg rocuronium.
curium (but not vecuronium) were found to enhance At the end of surgery, 0.03 mg/kg neostigmine and 0.006 mg/kg the increases in pulmonary resistance induced by vagus glycopyrrolate were administered to the patient for antagonism of nerve stimulation, probably by blocking prejunctional mus- residual neuromuscular block. The patient had an uneventful recovery.
carinic receptors (M2) that physiologically inhibit vagally No further bronchospasm was noted during her postoperative course.
mediated increases in pulmonary resistance.4,5 Blockage ofM3 muscarinic receptors on airway smooth muscle inhibits Discussion
vagally induced bronchoconstriction.5 Pancuronium and Although the overall reported incidence of broncho- gallamine had affinities for the M2 muscarinic receptor spasm (in controlled trials) after rapacuronium and suc- within the clinical dose range.6 The affinity of rapacuro- cinylcholine were 3.2 and 2.1%, respectively (data from nium for muscarinic receptors has not been studied. There- Organon Inc., West Orange, NJ), others1 noted 18 inci- fore, there is insufficient evidence to make a definite state- dents of such events (10.7%) after rapacuronium com- ment on how rapacuronium induces bronchospasm. It pared with 7 cases (4.1%) after succinylcholine. In the seems prudent, therefore, to avoid using rapacuronium in latter study, only one patient in the rapacuronium group, patients with asthma or airway hyperreactivity.
who had a history of obstructive airway disease, hadsevere bronchospasm after intubation.1 Our patient had References
severe bronchospasm after rapacuronium despite the 1. Sparr HJ, Mellinghoff H, Blobner M, Nolge-Schoniburg G: Comparison of facts that she was not asthmatic and that she received intubating conditions after rapacuronium (Org 9487) and succinylcholine follow- propofol for induction. Kahwaji et al.2 reported two ing rapid sequence induction in adult patients. Br J Anaesth 1999; 82:537– 41 2. Kahwaji R, Bevan DR, Bikhazi G, Shanks CA, Fragen RJ, Dyck JB, Angst MS, serious adverse effects (tachycardia and bronchospasm) Matteo R: Dose-ranging study in younger adult and elderly patients of ORG 9487, a that occurred in a 29-yr-old, 100-kg man with American new rapid-onset, short-duration muscle relaxant. Anesth Analg 1997; 84:1011– 8 3. Levy JH, Pitts M, Thanopoulos A, Szlam F, Bastian R, Kim J: The effects of Society of Anesthesiologists physical status I within 30 s rapacuronium on histamine release and hemodynamics in adult patients under- of administration of 2.0 mg/kg rapacuronium.
going general anesthesia. Anesth Analg 1999; 89:290 –5 4. Vettermann J, Beck KC, Lindahl SG, Brichant JF, Rehder K: Actions of Rapacuronium may release histamine and produce enflurane, isoflurane, vecuronium, atracurium, and pancuronium on pulmonary slight changes in blood pressure and heart rate after resistance in dogs. ANESTHESIOLOGY 1988; 69:688 –95 5. Okanlami OA, Fryer AD, Hirshman C: Interaction of nondepolarizing muscle administration.3 However, it seems that the broncho- relaxants with M and M muscarinic receptors in guinea pig lung and heart.
spasm noted with rapacuronium is mediated via mech- 6. Hou VY, Hirshman CA, Emala CW: Neuromuscular relaxants as antagonists anisms that do not seem to be related to histamine for M2 and M3 muscarinic receptors. ANESTHESIOLOGY 1998; 88:744 –50 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Bronchospasm after Rapacuronium in Infants and Children George H. Meakin, M.D.,* Erik H. Pronske, M.D.,Jerrold Lerman, M.D.,Rosemary Orr, M.D.,§ Denise Joffe, M.D.,ʈ Anne M. Savaree, M.D.,# Anne M. Lynn, M.D.** IN December 2000, subscribers to the Paediatric Anaesthesia pression, and a capnogram trace appeared. At this time, the oxygen Conference discussion group ϽPAC@anaes.sickkids.on.caϾ saturation percentage was in the low 80s. Epinephrine 50 ␮g wasadministered intravenously with continued improvement in chest com- were invited to post their experiences with rapacuronium pliance and oxygen saturation. When the airways had stabilized, sur- (Raplon; Organon Inc., West Orange, NJ) in children in the gery proceeded uneventfully. Recovery was uneventful.
USA. Specific side effects or responses to rapacuroniumwere neither requested nor encouraged. The postingsyielded 19 cases of bronchospasm, of which 12 were de- Case 2
scribed as severe, from six respondents. These reports The patient was a 41/2-yr-old girl who presented to the emergency caused such concern that the respondents felt obliged to department with the sudden onset of a prolonged seizure. The seizure bring this to the attention of their colleagues. Three of the had been treated with rectal diazepam. An anesthesiologist was con- sulted to intubate the trachea electively because of increasing respira-tory distress. Medical history included a mild upper respiratory tractinfection without fever or anorexia. Chest radiography was unremark- Case Reports
able. Additional history included spina bifida, panhypopituitarism, cho-anal atresia, developmental delay, and reactive airways disease. Medi- Case 1
cation history included phenobarbital, hydrocortisone, L-thyroxine,growth hormone, and albuterol prn. There were no known allergies.
The patient was a 12-yr-old, 64-kg boy with a diagnosis of acute The child had a fever of 40°C. Hydrocortisone was administered appendicitis. He had a history of mild reactive airways disease that was intravenously. Immediately after a single dose of both propofol and characterized by occasional use of an albuterol inhaler but no previous rapacuronium, the anesthesiologist noted “severe bronchospasm, hospital stays. His last occurrence of wheezing was 1–2 months before dropping oxygen saturations, very difficult to ventilate.” The child then this admission. Chest examination results were unremarkable. In the experienced asystole for 30 s, with a return of the pulse after a single operating room, a rapid sequence induction consisting of 1 mg intra- dose of epinephrine. Chest radiography after stabilizing the child venous midazolam, 75 ␮g fentanyl, 200 mg propofol, and 100 mg revealed bilateral pneumothoraces. After treating these, the child was rapacuronium was performed. Cricoid pressure was applied, and the trachea was intubated by the resident. When squeezing the reservoirbag, the resident reported that the tube was not “in the trachea” andremoved it. After reintubation, he remained unable to ventilate thelungs. No expired carbon dioxide was noted on the capnograph. The Case 3
staff knew the tube had passed into the trachea, but when the staff The patient was a 3-week-old, 3.4-kg healthy infant who presented squeezed the reservoir bag, it felt like “ventilating cement.” After for pyloromyotomy. After the stomach was suctioned, a rapid se- albuterol and isoflurane were administered by inhalation and a dose of quence induction was performed using 10 mg propofol, 7 mg rapacu- vecuronium, chest movement gradually became evident with bag com- ronium, and 0.050 mg intravenous atropine. The trachea was intu-bated, but there was no capnogram trace after two breaths. The tubewas removed and the trachea was reintubated. Again, there was no This article is accompanied by an Editorial View. Please see: capnogram trace. After confirming by direct laryngoscopy that the Goudsouzian NG: Rapacuronium and bronchospasm. ANESTHE- tube passed through the vocal cords, the lungs were ventilated vigor- ously for 60 –90 s with 100% oxygen. During that time, air entry waspoor and bronchospasm was auscultated bilaterally. At this time, thechest appeared to move somewhat with inflation. The pulse oximeterdid not register an oxygen saturation during this period, and heart rate * Senior Lecturer in Paediatric Anaesthesia, University Department of An- slowed. As bradycardia developed, a capnogram trace began to appear, aesthesia, Royal Manchester Children’s Hospital.
Children’s Hospital of Austin, Austin, Texas.
and, soon thereafter, the pulse oximeter registered a saturation of and Siemens Chair in Paediatric Anaesthesia, University of Toronto, 99%.There was no evidence of a rash. With the return of the capno- Hospital for Sick Children, Toronto, Canada.
gram trace and an oxygen saturation reading, surgery and anesthesia thesiology and Pediatrics, ** Professor of Anesthesiology and Pediatrics, Uni- versity of Washington, Seattle, Washington.
thesiology and Pediatrics, Children’s National Medical Center, Washington,DC.
# Assistant Professor of Anesthesiology and Pediatrics, University of Maryland Medical System, Baltimore, Maryland.
Discussion
Received from the Department of Anaesthesia, Royal Manchester Children’s Hospital, University of Manchester, Pendlebury, Manchester, United Kingdom.
Submitted for publication January 11, 2001. Accepted for publication February A total of 19 cases of bronchospasm after rapacuro- 27, 2001. Support was provided solely from institution and/or departmental nium were reported to the discussion group. All of the sources. Dr. Meakin has received funding for research regarding the drug rapa-curonium by Organon Teknika bv, Boxtel, The Netherlands.
events occurred in children, whose ages ranged from Address reprint requests to Dr. Meakin: University Department of Anaesthesia, infancy to adolescence. Four of the children had a con- Royal Manchester Children’s Hospital, Manchester M27 4HA, United Kingdom.
firmed history of reactive airways disease, whereas one Address electronic mail to: george.meakin@man.ac.uk. Individual article reprintsmay be purchased through the Journal Web site, www.anesthesiology.org.
did not. In two cases, rapacuronium was used to facili- tate a rapid sequence induction of anesthesia. In the 12 ing bronchospasm in pediatric patients. One author, cases of severe bronchospasm, the onset of symptoms who contributed 2 of the 19 cases, subsequently re- was rapid, with extreme stiffness of the lungs noted viewed her institutional experience with rapacuronium immediately after intubation and absence of the end-tidal and identified a total of 8 cases of bronchospasm after carbon dioxide trace. In three cases, intubation of the rapacuronium for an incidence of 8 in 500 (1.6%). This trachea was questioned because the lungs were unchar- incidence is consistent with a published incidence of acteristically stiff to ventilate, and the capnogram trace 1.2% in infants and children1 and 1.1% in adults2 (al- was absent. However, laryngoscopy confirmed correct though incidences as great as 8.3% and 14.8% have been placement of the tube. Some of the respondents stated reported in adults).3,4 Some of the anesthetists involved that this was the worst postintubation bronchospasm with these cases are now reluctant to use rapacuronium they had ever encountered, others that it was like trying in infants or children with a history of reactive airway to “ventilate a brick” or “ventilate cement.” disease or in those in whom bronchospasm would be Reddening of the skin (a possible sign of histamine tolerated poorly. Readers should be aware of this poten- release) was noted in one patient. The absence of clini- tially serious side effect of rapacuronium and are encour- cal evidence of histamine release was noted specifically aged to report all adverse events after administration in five other patients. In one of these, plasma histamine ofrapacuronium to the Food and Drug Administration concentration measured within 5 min of the event was normal. Treatment for the bronchospasm included in-creasing the level of anesthesia, increasing the adminis- References
tration of albuterol or epinephrine, or both. However,most cases resolved spontaneously after a few minutes, 1. Meakin GH, Meretoja OA, Motsch J, Taivainen T, Wirtavuori K, Schönstedt and none lasted more than 10 min. Additional complica- R, Perkins R, McCluskey A: A dose-ranging study of rapacuronium in pediatricpatients. ANESTHESIOLOGY 2000; 92:1002–9 tions that were observed included hemoglobin oxygen 2. Kahwaji R, Bevan DR, Bikhazi G, Shanks CA, Fragen RJ, Dyck JB, Angst MS, desaturation in one child and bilateral pneumothoraces Matteo R: Dose-ranging study in younger adults and elderly patients of ORG 9487,a new, rapid onset, short duration muscle relaxant. Anesth Analg 1997; 84: Although the details from some of the cases are incom- 3. Sparr HJ, Mellinghoff H, Blobner M, Noldge-Schomburg G: Comparison of intubating conditions after rapacuronium (Org 9487) and succinylcholine follow- plete, together, these experiences suggest an association ing rapid sequence induction in adult patients. Br J Anaesth 1999; 82:537– 41 between administration of rapacuronium and the abrupt 4. Levy JH, Pitts M: The effects of rapacuronium on histamine release and hemodynamics in adult patients undergoing general anesthesia. Anesth Analg development of severe, albeit short-lived and self-limit- 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
High-frequency Jet Ventilation in Life-threatening Bilateral Bruno Riou, M.D., Ph.D.,* Khaled Zaier, M.D.,Pierre Kalfon, M.D.,Louis Puybasset, M.D., Ph.D.,Pierre Coriat, M.D.,§ Jean-Jacques Rouby, M.D., Ph.D.* TRAUMA is the leading cause of death among young monary contusion may lead to severe hypoxia and hy- people in developed countries.1 Because up to 80% of percarbia, which cannot be adequately controlled using trauma deaths occur during the first 24 h after trauma,1 conventional mechanical ventilation. Hypoxia and hy- early resuscitation and rapid assessment of trauma le- percarbia may have deleterious effects, such as enhance- sions are of paramount importance to improving the ment of brain injury and development of circulatory prognosis. Among traumatic lesions, pulmonary contu- shock.5 In the most severe cases, aggressive therapeutic sion is frequent but has not been recognized as an methods, such as extracorporeal membrane oxygen- independent prognosis factor.2– 4 In very few cases, pul- ation (ECMO), have been reported.6 At our institution,high-frequency jet ventilation (HFJV) has been used rou- * Professor of Anesthesiology, † Resident in Anesthesiology, ‡ Assistant Profes- tinely for many years for the treatment of severe acute sor of Anesthesiology, § Professor of Anesthesiology and Chairman.
respiratory distress syndrome.7,8 We report a series of From the Department of Anesthesiology and Critical Care, Centre Hospitalier severe trauma patients with life-threatening pulmonary Universitaire Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France.
Submitted for publication January 14, 2000. Accepted for publication October contusion successfully treated with HFJV when the con- 12, 2000. Support was provided solely from institutional and/or departmental ventional mechanical ventilation approach failed to pro- Address reprint requests to Dr. Riou: Départment d’ Anesthésie-Réanimation, vide appropriate gas exchange. The current data suggest CHU Pitié-Salpêtrière, 47 Boulevard de l’ Hôpital, 75651 Paris Cédex 13, France.
that HFJV can be a life-saving technique in severely Address electronic mail to: bruno.riou@psl.ap-hop-paris.fr. Individual article re-prints may be purchased through the Journal Web site, www.anesthesiology.org.
hypoxemic patients with bilateral pulmonary contusion.
Table 1. Evolution of the Main Hemodynamic, Ventilatory, and Arterial Blood Gas Parameters in Nine Patients with Life-
threatening Pulmonary Contusion during Conventional Mechanical Ventilation and High-frequency Jet Ventilation (HFJV)

Initial data with HFJV were obtained within 1 h after the onset of HFJV. Data are mean Ϯ SD.
* P Ͻ 0.05 versus admission. † P Ͻ 0.05 versus conventional ventilation.
PaCO ϭ arterial partial pressure of carbon dioxide; Pa ϭ arterial partial pressure of oxygen; F ϭ inspired fraction of oxygen; EEP ϭ end-expiratory pressure; ϭ mean airway pressure; MAP ϭ mean arterial pressure.
Patients and Methods
ity score (ISS), probability of survival according to theTrauma and Injury Severity Score (TRISS) methodolo- During a 6-yr period (1990 –1996), 1,241 severe gy,11 and the Lung Injury Severity Score. (LIS)12 trauma patients were admitted to our Level 1 Trauma High-frequency jet ventilation was performed using an Centre. All trauma patients who received HFJV during AMS 1000 ventilator (Acutronic Medical Systems AG, the first 24 h after admission were identified and in- Hirzel, Switzerland). Rewarming and humidification of cluded in the study. One of these patients has been gases were provided by a HH-812 Jet humidifier (Acu- reported previously.9 The decision to perform HFJV wasmade by the senior anesthesiologist in charge of the tronic Medical Systems). Additional conventional venti- emergency room because of the severity of pulmonary lation (low rate, 4 – 6 breaths/min; low tidal volume, contusion. All patients fulfilled the following criteria: (1) 75–100 ml) was obtained using a CPU 1 ventilator (Ohm- eda, Maurepas, France). Mean airway pressure was mon- with an inspired fraction of oxygen (FIO ) of 100%; (2) itored continuously with a catheter located in the tra- progressive decrease in PaO during the last hours with- chea 10 cm distal to the tip of the injector cannula, as out any trend to stabilization or improvement; (3) failure of further increases in positive end-expiratory pressure Data are mean Ϯ SD. Comparison of several means was (PEEP) to improve PaO or impossibility to increase PEEP performed using repeated-measures analysis of variance.
because of hemodynamic consequences; (4) bilateral A P value less than 0.05 was considered significant.
pulmonary contusion. An anesthesiologist and a nursefrom the surgical intensive care unit initiated and ad-justed HFJV in the emergency room. The decision toimplement HFJV during the early period after traumaadmission always was related to severe hypoxemia orcirculatory shock. We did not include patients in whomHFJV was initiated because of systemic gas embolismrelated to pulmonary contusion.10 The following data were collected: age; sex; trauma lesions; administration of colloids, crystalloids, blood,and catecholamines; duration of stay in intensive careunit; and mortality. The following ventilatory parameterswere recorded during conventional mechanical ventila-tion: ventilatory rate, tidal volume, and PEEP. The fol-lowing parameters were measured at admission, duringconventional mechanical ventilation, just before HFJV,15–30 min after HFJV, and 24 h after admission: arterial Fig. 1. Evolution of the partial pressure of oxygen/inspired
pH, PaO and partial pressure of carbon dioxide (Pa fraction of oxygen (PaO /F
) ratio during the first 24 h in nine
patients with life-threatening pulmonary contusion. Initial data
ratio, mean arterial pressure measured using an with high-frequency jet ventilation (HFJV) were obtained
indwelling radial or femoral artery catheter, and heart within 1 h after the onset of HFJV. CV ؍ conventional mechan-
rate. The following indices were calculated: injury sever- ical ventilation; 24 hrs: 24 h after admission, during HFJV.
fully in all the remaining patients. These results confirmprevious reports that suggest that HFJV can be effective as Over a 6-yr period, HFJV was used during the first 24 h a rescue therapy for refractory acute lung dysfunction.13,14 after admission in nine patients (six male, three female) The current study cannot definitely assess the mecha- because of life-threatening hypoxemia related to pulmo- nisms involved in the beneficial effect of HFJV. Because nary contusion. The incidence of life-threatening pulmo- of the emergency and critical conditions, a pulmonary nary contusion defined by this criteria was 0.73% (95% computed tomography scan could not be obtained in confidence interval, 0.26 –1.20%). The mean age was most of these patients at the early phase. Nevertheless, 29 Ϯ 15 yr (range, 8 –58 yr), the mean ISS was 50 Ϯ 17 thoracic radiography highly suggested that diffuse pul- (range, 20 –75), the mean TRISS was 0.63 Ϯ 0.36 (range, monary contusion occurred, and thus that alveolar re- 0.08 – 0.96), and the mean LIS was 3.4 Ϯ 0.3 (range, cruitment induced by HFJV was likely the main mecha- 3– 4). These scores signify severe multisystem injuries.
nism responsible for the marked increase in PaO2 Associated head trauma was present in seven patients, observed in our patients. HFJV is known to induce an abdominal trauma was present in four patients, spine increase in functional residual capacity by trapping in- trauma was present in four patients, and pelvic trauma in trapulmonary gases because of incomplete exhalation was present in two patients. All patients had severe during the short expiratory time (auto-PEEP effect). Two thoracic trauma with bilateral pulmonary contusion.
other mechanisms should be considered. First, closure Chest radiography showed bilateral extensive and dif- of a patent foramen ovale may have reduced hypoxemia, fuse alveolar hyperdensities in all cases. Other traumatic as previously reported.15 However, it should be noted thoracic lesions included hemothorax in three patients, that an increase in pulmonary artery pressure (potential- pneumothorax in two patients, and aortic rupture in one ly leading to right-to-left intracardiac shunt) usually is not patient. All patients underwent transesophageal echocar- observed at the very early stage of pulmonary contusion diography: mean left ventricular ejection fraction was 45 and that we failed to find evidence of any patent foramen Ϯ 29% (range, 10–71%), myocardial contusion was ob- ovale using transesophageal echocardiography in five of served in five patients, and three patients had severe these patients. Second, an improvement in hemody- decrease in left ventricular ejection fraction (Ͻ 30%). A namic conditions may have contributed to the HFJV- search for a patent foramen ovale was performed in five induced increase in PaO . This last effect can be complex patients; all results were negative. During the first 24-h because an increase in cardiac output can decrease PaO2 period, fluid resuscitation consisted of 1.8 Ϯ 1.3 l crys- through capillary recruitment but also can increase PaO2 talloids, 3.7 Ϯ 1.8 l colloids, 7 Ϯ 8 units packed eryth- through an increase in mixed venous oxygen saturation.
rocytes, 3 Ϯ 3 units fresh frozen plasma, and 4 Ϯ 5 In patients with septic shock, Fusciardi et al.16 have platelet units. Catecholamines were administered in shown that mean arterial pressure and cardiac output are eight patients (epinephrine in three patients, norepi- higher during HFJV than during conventional mechani- nephrine in four patients, dopamine in five patients, and cal ventilation when compared at the same airway pres- dobutamine in one patient). After HFJV, the dose of sure and PaCO . However, this hemodynamic improve- catecholamines was decreased in six patients and in- ment was associated with a small deterioration in arterial Tracheal intubation was performed in all patients dur- Because the mean PEEP value was not high in our ing the early resuscitation phase (delay, 51 Ϯ 68 min study, one can argue that a marked increase in PEEP after trauma). HFJV was initiated 7 Ϯ 6 h after trauma.
might have induced an effect similar to that observed Table 1 shows the evolution of the main hemodynamic, with HFJV. In our patients, such an increase in PEEP ventilatory, and blood gas parameters. Figure 1 depicts could not be applied without marked alteration in he- modynamic conditions. Associated right ventricle contu- The mean stay in the intensive care unit was 40 Ϯ sion is likely to explain that our patients poorly tolerated 38 days. Death occurred in four patients and was always any further increase in intrathoracic pressure.9 At an related to severe brain injury. In the five surviving patients, identical level of mean airway pressure, HFJV is better HFJV was maintained for 7 Ϯ 5 days (range, 3–15 days).
hemodynamically tolerated than PEEP in shocked pa-tients.17 It should be pointed out that high PEEP is Discussion
associated with high peak inspiratory pressure that canbe harmful in patients with pulmonary contusion be- We report that HFJV dramatically increased PaO in a cause it increases pulmonary edema,18 causes baro- group of trauma patients with life-threatening hypox- trauma through alveolar rupture, and facilitates pulmo- emia related to bilateral pulmonary contusion. Despite nary venous gas embolism.10 It has been demonstrated severe pulmonary contusion, death always occurred be- recently that reducing tidal volume during mechanical cause of brain injury and not because of pulmonary ventilation in ARDS decreases mortality.19 High PEEP contusion, and weaning of HFJV was obtained success- and low tidal volume induce hypercapnia that is delete- rious in patients with head trauma. As shown in table 1, 6. Voeckel W, Wenzel V, Rieger M, Antretter H, Padosch S, Schobersberger W: Temporary extracorporeal membrane oxygenation in the treatment of acute traumatic lung injury. Can J Anaesth 1998; 45:1044 – 8 severe life-threatening pulmonary contusion. Moreover, 7. Rouby JJ, Simonneau G, Benhamou D, Sartene R, Sardnal F, Deriaz H, Duroux P, Viars P: Factors influencing pulmonary volumes and CO elimination the fluid loading required to overcome the hemody- during high-frequency jet ventilation. ANESTHESIOLOGY 1985; 63:473– 82 namic effects of PEEP on venous return also may in- 8. Rouby JJ, Viars P: Clinical use of high frequency jet ventilation. Acta Anaesthesiol Scand 1989; 90(suppl):134 –9 9. Orliaguet G, Jacquens Y, Riou B, Le Bret F, Rouby JJ, Viars P: Combined In conclusion, in rare cases of severe bilateral pulmo- severe myocardial and pulmonary contusion: Early diagnosis with transesopha-geal echocardiography and management with high-frequency jet ventilation.
nary contusion refractory to conventional mechanical ventilation, HFJV may be a life-saving procedure. Be- 10. Saada M, Goarin JP, Riou B, Rouby JJ, Jacquens Y, Guesde R, Viars P: Systemic gas embolism complicating pulmonary contusion: Diagnosis and man- cause of the rarity of these cases, there is a low possibil- agement using transesophageal echocardiography. Am J Respir Crit Care Med ity that a randomized trial could ever be conducted.
Therefore, traumatologists, intensivists, and anesthesiol- 11. Boyd CR, Tolson MA, Copes WS: Evaluating trauma care: the TRISS ogists should be aware of this therapeutic possibility and 12. Murray JF, Matthay MA, Luce JM, Flick MR: An expanded definition of the should try HFJV before irreversible consequences of adult respiratory distress syndrome. Am Rev Respir Dis 1988; 138:720 –3 13. Borg UR, Stoklosa JC, Siegel JH, Wiles CE, Belzberg H, Blevins S, Cotter K, hypoxemia or hypercarbia occur in these severe trauma Laghi F, Rivkind A: Prospective evaluation of combined high-frequency ventila- patients. Moreover, HFJV is probably a more simple tion in post-traumatic patients with adult respiratory distress syndrome refractoryto optimized conventional ventilatory management. Crit Care Med 1989; 17: procedure than ECMO, which sometimes has been used in such patients6 but usually is contraindicated in severe 14. Claridge JA, Hostetter RG, Lowson SM, Young JS: High-frequency oscilla- tory ventilation can be effective as rescue therapy for refractory acute lung 15. Fellahi JL, Mourgeon E, Goarin JP, Law-Koune JD, Riou B, Coriat P, Rouby JJ: Inhaled nitric oxide-induced closure of a patent foramen ovale in a patientwith acute respiratory distress syndrome and life-threatening hypoxia. ANESTHESI- References
16. Fusciardi J, Rouby JJ, Barakat T, Mal H, Godet G, Viars P: Hemodynamic 1. Capan LM, Miller SM, Turndorf H: Trauma overview, Trauma Anesthesia and effects of high-frequency jet ventilation in patients with and without circulatory Intensive Care. Edited by Capan LM, Miller SM, Turndorf H. Philadelphia, Lip- 17. Rouby JJ, Houissa M, Brichant JF, Baron JF, McMillan C, Arthaud M, 2. Clark GC, Schechter WP, Trunkey DD: Variables affecting outcome in blunt Amzallag P, Viars P: Effects of high-frequency jet ventilation on arterial baroreflex chest trauma: flail chest vs. pulmonary contusion. J Trauma 1988; 28:298 –304 regulation on heart rate. J Appl Physiol 1987; 63:2216 –22 3. Johnson JA, Cogbill TH, Winga ER: Determinants of outcome after pulmo- 18. Dreyfuss D, Soler P, Basset G, Saumon G: High inflation pressure pulmo- nary contusion. J Trauma 1986; 26:695–7 nary edema: Respective effects of high airway pressure, high tidal volume and 4. Hoff SJ, Shotts SD, Eddy VA, Morris JA: Outcome of isolated pulmonary positive expiratory pressure. Am Rev Respir Dis 1988; 137:1159 – 64 contusion in blunt trauma patients. Am Surg 1994; 60:138 – 42 19. The Acute Respiratory Distress Syndrome Network: Ventilation with lower 5. Wilson RF, Gibson DB, Antoneko D: Shock and acute respiratory failure tidal volumes for acute lung injury and the acute respiratory distress syndrome.
after chest trauma. J Trauma 1977; 17:697–705 2001 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
Jet Ventilation for Fiberoptic Bronchoscopy Ivan David, M.D.,* Miloslav Marel, M.D., C.Sc.,Renata Pipková, M.D.,Jirˇı´ Najbrt, M.D.,§ Pavel Vychodil, M.D.,ʈ Jan Schützner, M.D., C.Sc.,# Pavel Pafko, M.D., Dr.Sc.** ACUTE pulmonary or lobar collapse is a troublesome After tracheal resection, airway management for fiber- complication after thoracic surgery and may mandate optic bronchoscopy in patients with general anesthesia aggressive intervention. Therapeutic fiberoptic bron- is frequently difficult, particularly in cases in which the choscopy is a standard intervention for the treatment of resected tracheal segment is long (e.g., 4 –5 cm) and the atelectasis in the intensive care setting.1 degree of postoperative neck flexion is necessarily ex-treme. We report a case of intermittent low-frequencyjet ventilation, applied via the instrument channel of a * Consultant Cardiothoracic Anaesthetist, § Consultant Anaesthetist, ʈ Regis- flexible fiberoptic bronchoscope (FFB), for the emer- trar Anaesthetist, Department of Anesthesia and Intensive Care, † Assistant Pro- gency treatment of postoperative atelectasis after tra- fessor, Department of Respiratory Medicine, ‡ Consultant Radiologist, Depart-ment of Radiology, 2nd School of Medicine, # Assistant Professor, ** Professor of Surgery, 3rd Department of Surgery, 1st School of Medicine, Motol UniversityHospital Prague.
Received from the Department of Anesthesia and Critical Care, Motol Univer- Case Report
sity Hospital, Prague, Czech Republic. Submitted for publication July 6, 2000.
Accepted for publication December 1, 2000. Supported by the National HealthInsurance System (The General Health Insurance Company, Prague, Czech An 18-yr-old male underwent cardiopulmonary resuscitation after Republic). Presented at the annual meeting of the European Cardiothoracic arrhythmia complicating acute myocarditis. After 3 days of ventilatory Intensive Care Workgroup, London, United Kingdom, October 14, 2000.
support, he was extubated successfully and was discharged subse- Address reprint requests to Dr. David: Department of Anesthesia and Intensive quently. Six weeks later, he was referred to our university hospital. At Care, Motol University Hospital, V Úvalu 84, 150 06 Praha 5, Czech Republic.
the time of presentation, he exhibited respiratory distress with inspira- Address electronic mail to: ivan.david@volny.cz. Individual article reprints maybe purchased through the Journal Web site, www.anesthesiology.org.
tory and expiratory stridor. Rigid bronchoscopy revealed severe tra- cheal stenosis just below the cricoid cartilage. Electrocoagulation and The optimum technique for airway management was dilatation were performed, and the patient was able to breathe spon- the subject of much deliberation in this case. Extreme taneously and comfortably after the procedure. A spiral computed forward tilting of the head prevented insertion of a tomography scan 2 days later showed the stenosis to extend 40 mmfrom its proximal origin, 30 mm below the vocal cords, with an ID of laryngeal mask airway2 or an endotracheal tube via a traditional intubation technique. In addition, the possi- One week after this admission, tracheal resection was performed. A bility of direct tracheal suture injury, even with careful tracheal segment of 45 mm in length was resected, followed by insertion of the endotracheal tube, was of great concern.
end-to-end suture. The length of resection rendered head extensionimpossible. As per our protocol, the patient was extubated immedi- Finally, we opted for the combination of intravenous ately after surgery and was transferred subsequently to the surgical anesthesia and manual ventilation via face mask as intensive care unit. After an initial stable course, on the first postop- erative day, he had a substantial decrease in peripheral oxygen satura- There is very limited information in the literature tion (SpO ) to 81%. Chest radiography showed complete atelectasis of about the use of the instrument (“suction”) channel of the left lung. We elected to perform fiberoptic bronchoscopy duringgeneral anesthesia with manual ventilation via face mask.
the FFB for jet ventilation. In 1980, Satyanarayana et al.3 After induction of anesthesia by titration of propofol up to a dose of evaluated this technique in animals and in eight adult 2.5 mg/kg, we initially verified that manual ventilation via face mask volunteers scheduled to undergo minor surgery. He ob- was feasible. We then commenced an infusion of propofol at the usual served excellent arterial oxygenation and hypocarbia dose of 9 mg · kgϪ1 · hϪ1 (i.e., 150 ␮g · kgϪ1 · minϪ1). Topical lidocainewas applied to the larynx via the instrument channel of the FFB, and and reported no complications. Dalens et al.4 reported a it proved unnecessary to administer muscle relaxants. The FFB passed series of 49 pediatric patients with respiratory distress, easily through the tracheal anastomosis to the tracheal bifurcation, and aged 3 days to 3 yr, who underwent bronchoscopic no signs of recent bleeding were noted. A thick, white mucous plug examination using a similar technique. As in our report, was identified, situated 1 cm below the orifice of the left main bron- after every distal exploration, the FFB tip was withdrawn chus. We instilled a mucolytic preparation and commenced suctionclearance of the plug and other secretions.
to above the carina to ensure bilateral pulmonary insuf- Unfortunately, the mucous proved extremely tenacious, and the flations, which were then given for 15 s at a respiratory procedure was complicated by recurrent decreases in SpO to unac- rate of 50 to 60 breaths/min. Gas exchange was accept- ceptable levels. It proved necessary to repeatedly interrupt fiberoptic able, and no complications were observed.
bronchoscopy to reestablish more effective manual ventilation. Afterrepeated interruptions and ongoing recurrent desaturations, we de- In the latest report, Baraka5 applied a similar technique in a 2-yr-old child who was scheduled for bronchoscopy We used the Paravent PAT ventilator (Elmet Ltd., Prˇelouc because of atelectasis and pneumonic infiltrates. Unfor- Republic). This device features a high-powered jet nozzle and incor- tunately, the pediatric bronchoscope (3.4 mm OD) porates a Venturi principle to enhance administered gas volume. We could not pass easily through a 4-mm endotracheal tube.
connected the jet to the suction channel (2.2 mm diameter) of the FFB(Olympus BF 20D, Tokyo, Japan). We then ventilated with pure oxy- He tried to perform the procedure via a size 2 laryngeal gen using a low-frequency regime at a respiratory rate of 20 breaths/ mask airway (7.0 mm ID), which was technically feasi- min and a driving pressure of 80 kPa (600 mmHg or 12 psi). Inspiratory ble, but low lung compliance made mechanical ventila- to expiratory time ratio was set at 1:1. The tip of the FFB was placed tion difficult, and, after a decrease in SpO to 85%, inter- Using this approach, we were able to achieve Sp mittent jet ventilation of oxygen via the instrument 95%, and it proved possible to continue the procedure in a controlled channel ensured adequate oxygenation.
and safe fashion. Chest excursion could be easily observed clinically, These latter two reports imply that the technique can and, at the end of the procedure, chest excursions were symmetrical.
be used safely even in patients with ventilatory compro- When SpO decreased to 90%, we interrupted suction and repeated the mise.4,5 Although they involved children, we believe that jet ventilation maneuver. For vigorous bronchial toilet and to encour-age mobilization of secretions, the patient underwent ventilation for a the principles involved may be equally applicable in brief period (three times for 1 or 2 min) using a high-frequency mode with a respiratory rate of 180 breaths/min. Finally, we awakened the One of the obvious risks of this approach is the poten- patient, and the subsequent chest radiography clearly documented tial for inadvertently causing barotrauma if the tip of the successful treatment with reexpansion of the left lung.
FFB slips beyond the carina and “wedges” in a bronchus.
The added advantage of jetting via the instrument chan- Discussion
nel of the FFB is that the position of the jet source can bedirectly controlled visually, thus enhancing the safety of This case highlights two particular difficulties that may the procedure. Excessive hyperinflation must be avoided be faced in the management of pulmonary atelectasis also, and effective exhalation must be ensured. The FFB after tracheal reconstruction. First, extreme flexion of OD is 5.8 mm, whereas the narrowest lumen diameter of the neck presents substantial difficulties for securing a the normal tracheal segments was measured by com- stable airway during an anesthetic procedure. In addi- puted tomography as 15 mm. Therefore, difficulties with tion, there is the potential for direct damage to the exhalation are more likely to originate at laryngeal or tracheal anastomoses from any tracheal instrumentation, upper airway level and can be minimized by ensuring a particularly from blindly placed endotracheal tubes.
clear airway. If gas trapping is still a feature, it is easily recognized clinically and can be managed simply by and reinsertion of the FFB when applying face mask intermittent interruption of jet ventilation.
Another risk, albeit theoretical, that should be consid- ered is the possibility of direct damage to the FFB. The The authors thank Brian F. Keogh, M.D., F.R.C.A., Consultant Cardiothoracic Anaesthetist, The Royal Brompton Hospital, London, United Kingdom, for his instrument channel in this type of FFB is a polytetrafluo- most useful comments and assistance in preparing the manuscript.
roethylene tube and is unlikely to be damaged if itremains patent. In addition, the risk that the channelcould be blocked so tightly that it could lead to a rupture References
1. Dellinger RP: Fiberoptic bronchoscopy in critical care medicine, Textbook Although the indications for jet ventilation via the of Critical Care, 3rd edition. Edited by Shoemaker WC, Ayres SM, Grenvik A,Holbrook PR. Philadelphia, WB Saunders, 1995, pp 761–71 instrument channel of an FFB may be rare, they are more 2. Atherton DP, O’Sullivan E, Lowe D, Charters P: A ventilation-exchange likely to be applicable in a challenging situation and bougie for fibreoptic intubations with the laryngeal mask airway. Anaesthesia1996; 51:1123– 6 particularly in the presence of a difficult airway manage- 3. Satyanarayana T, Capan L, Ramanathan S, Chalon J, Turndorf H: Broncho- ment problem. In this case report, the technique greatly fiberscopic jet ventilation. Anesth Analg 1980; 59:350 – 4 4. Dalens B, Labbe A, Haberer JP: Respiratory assistance secured by jet- facilitated the therapeutic procedure and enhanced its ventilation during broncho-fiberscopy in forty-nine infants. ANESTHESIOLOGY 1982; safety. In addition, it decreased the risk of inadvertent 5. Baraka A: Jet ventilation via the suction port during fibreoptic bronchos- tracheal trauma caused by the need for frequent removal copy in a child. Paediatr Anaesth 1997; 7:87– 8

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