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Cherie P. Erkmen, MD; Vignesh Raman, BS
Author and Funding Information

From the Department of Thoracic Surgery (Dr Erkmen), Temple University Health Systems; and the Division of Thoracic Surgery, Department of Surgery (Mr Raman), Dartmouth-Hitchcock Medical School.

CORRESPONDENCE TO: Cherie P. Erkmen, MD, Department of Thoracic Surgery, Temple University Health Systems, Parkinson Pavilion, Ste C-100, Philadelphia, PA 19140; e-mail: Cherie.P.Erkmen@tuhs.temple.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have 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-e121. doi:10.1378/chest.14-2993
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To the Editor:

We thank Dr Carron for the insightful remarks about our recent article in CHEST.1 Using a porcine model, we demonstrated that 20, 30, and 40 cm H2O of supralaryngeal positive airway pressure resulted in esophageal pressures of 5 ± 4 cm H2O (25%), 11 ± 11 cm H2O (37%), and 15 ± 9 cm H2O (38%), respectively. This is a fraction of the pressure needed to disrupt an esophagogastric anastomosis.

We agree that noninvasive positive-pressure ventilation (NPPV) following esophagectomy may carry risks that need characterization in future studies. Our study showed variability in the pressure tolerance of anastomoses, as would be expected in the clinical setting. The lowest breaking pressure of 21 cm H2O in one ex vivo sample may be attributable to ischemia of the tissue after explantation. More significant to the clinical setting, the lowest threshold in vivo was 54 cm H2O. Our studies in human cadaveric esophagogastric anastomoses have demonstrated no pressure threshold below 59 cm H2O and a mean pressure threshold of 107 cm H2O (C. P. E., V. R., O. G. Ofoche, BS; unpublished data, January-August 2014). These models help establish the safe parameters for further study of NPPV in patients undergoing esophagectomy.

Dr Carron echoes our caution about gastric insufflation and aspiration with NPPV. In the setting of esophagectomy, gastric conduit distension may increase wall tension and decrease venous outflow, causing ischemia to the conduit and anastomosis.1,2 We agree with a comprehensive review of NPPV that advocates nasogastric tube decompression, airway pressures below 20 to 25 cm H2O, and minimization of tidal volume.3 Regarding the risk of aspiration, a European trial of NPPV after esophagectomy used nasogastric tube suction and found no increase in the incidence of aspiration pneumonia.4

Our work has shown that porcine gastric conduit and esophagogastric anastomoses can tolerate a much higher pressure than that received by the esophagus during NPPV. However, as outlined here and in our article, further human studies are necessary to firmly establish the safety of NPPV in patients undergoing 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]
 
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]
 
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]
 
Michelet P, D’Journo XB, Seinaye F, Forel JM, Papazian L, Thomas P. Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg. 2009;96(1):54-60. [CrossRef] [PubMed]
 

Figures

Tables

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]
 
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]
 
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]
 
Michelet P, D’Journo XB, Seinaye F, Forel JM, Papazian L, Thomas P. Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg. 2009;96(1):54-60. [CrossRef] [PubMed]
 
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