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Safety Considerations Regarding Noninvasive Positive Pressure Ventilation Following EsophagectomyNoninvasive Ventilation Following Esophagectomy FREE TO VIEW

Michele Carron, MD
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From the Department of Medicine, Anesthesiology and Intensive Care, University of Padova.

CORRESPONDENCE TO: Michele Carron, MD, Department of Medicine, Anesthesiology and Intensive Care, University of Padova, Via C. Battisti, 267, 35121 Padova, Italy; e-mail: michele.carron@unipd.it


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):e120. doi:10.1378/chest.14-2826
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To the Editor:

I read with great interest the article by Raman et al1 in a recent issue of CHEST (February 2015) that evaluated the pressure tolerance of esophagectomy anastomosis ex vivo and in vivo in a pig model in comparison with esophageal pressure during noninvasive positive-pressure ventilation (NPPV). The authors showed that anastomosis can tolerate higher pressures than those transmitted to the esophagus during NPPV, thus demonstrating the safety of NPPV after esophagectomy.1 Despite these data, however, in the clinical setting caution is necessary for several reasons when using pressures > 20 cm H2O during NPPV after esophagectomy.

First, the authors found significant variability in pressure tolerance using ex vivo and in vivo models.1 In their study, the lowest pressure tolerated by ex vivo anastomoses before leakage was 21 cm H2O.1

Second, the risk of gastric insufflation during NPPV increases with pressure > 20 cm H2O.2 Even if a pressure of ≤ 15 cm H2O is considered safe, a pressure of 15 to 20 cm H2O is also acceptable for preventing gastric insufflation during NPPV.2 During NPPV, the ventilation volume is distributed between the lungs and stomach, depending on the respiratory system resistance and the esophageal sphincter pressure.2 The resting upper esophageal sphincter pressure is lower in elderly individuals compared with young people (24 ± 9 mm Hg vs 42 ± 14 mm Hg, P < .001).3 Furthermore, the protective function of the lower esophageal sphincter is generally lost after esophagectomy.1 In clinical esophageal surgery, postoperative gastric distention not only may cause decreased venous outflow and vascular congestion within a gastric conduit,1 but increasing the wall tension may potentiate the ischemic effects of gastric transposition for esophageal reconstruction.4

Third, air escape from the stomach to the esophagus after gastric insufflation may induce transient upper esophageal sphincter relaxation.5 This effect is a consequence of receptor stimulation by the air pressure pulse in the esophagus, but not distention of the esophagus or an increase in esophageal pressure.5 Upper esophageal sphincter relaxation may allow aspiration of gastric contents that may be associated with serious complications (ie, pulmonary aspiration and pneumonia).2 These complications should be prevented and managed by nasogastric tube placement for intermittent air and fluid aspiration, if possible, as well as aggressive acid reduction (ie, via IV administration of proton pump inhibitors).4 Thus, great care should be used not only to limit an increase in esophageal pressure, but, most importantly, to also reduce the risk of esophageal-gastric insufflation during NPPV after esophagectomy.

References

Raman V, MacGlaflin CE, Erkmen CP. Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model. Chest. 2015;147(2):356-361. [CrossRef] [PubMed]
 
Carron M, Freo U, BaHammam AS, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. 2013;110(6):896-914. [CrossRef] [PubMed]
 
Amaris M, Dua KS, Naini SR, Samuel E, Shaker R. Characterization of the upper esophageal sphincter response during cough. Chest. 2012;142(5):1229-1236. [CrossRef] [PubMed]
 
Tang SJ, Daram SR, Wu R, Bhaijee F. Pathogenesis, diagnosis, and management of gastric ischemia. Clin Gastroenterol Hepatol. 2014;12(2):246-252. [CrossRef] [PubMed]
 
Lang IM, Medda BK, Shaker R. Mechanism of UES relaxation initiated by gastric air distension. Am J Physiol Gastrointest Liver Physiol. 2014;307(4):G452-G458. [CrossRef] [PubMed]
 

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References

Raman V, MacGlaflin CE, Erkmen CP. Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model. Chest. 2015;147(2):356-361. [CrossRef] [PubMed]
 
Carron M, Freo U, BaHammam AS, et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. Br J Anaesth. 2013;110(6):896-914. [CrossRef] [PubMed]
 
Amaris M, Dua KS, Naini SR, Samuel E, Shaker R. Characterization of the upper esophageal sphincter response during cough. Chest. 2012;142(5):1229-1236. [CrossRef] [PubMed]
 
Tang SJ, Daram SR, Wu R, Bhaijee F. Pathogenesis, diagnosis, and management of gastric ischemia. Clin Gastroenterol Hepatol. 2014;12(2):246-252. [CrossRef] [PubMed]
 
Lang IM, Medda BK, Shaker R. Mechanism of UES relaxation initiated by gastric air distension. Am J Physiol Gastrointest Liver Physiol. 2014;307(4):G452-G458. [CrossRef] [PubMed]
 
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