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Correspondence |

Noninvasive Ventilation and Risk of Leakage of Esophageal Anastomosis: A Matter of “Transesophageal Pressure”? FREE TO VIEW

Marco Giani, MD; Luigi Beretta, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Marco Giani, MD, Department of Anesthesia and Intensive Care, IRCCS Ospedale San Raffaele, via Olgettina 60, Milan, Italy


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(2):601-602. doi:10.1016/j.chest.2015.10.068
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We read with interest the physiologic article by Raman and colleagues in CHEST (February 2015). In the second in vivo experiment described in the article, five pigs were ventilated through a laryngeal mask airway and the pressure transmitted to the proximal esophagus was measured at increasing ventilatory pressures. The resulting pressure was negligible compared with that required to induce leakage at the anastomosis. The authors thus conclude that noninvasive ventilation (NIV) is a safe alternative to endotracheal intubation to treat respiratory distress after esophagectomy. However, this study has a relevant limitation.

The increase in esophageal pressure measured during mechanical ventilation does not reflect the stretch of the anastomosis. The distending force that stresses the wall of an organ depends on the differential pressure between inside and outside the organ. If the pressure is applied from outside, the organ will tend to collapse and no parietal strain develops. For example, as demonstrated by many articles on respiration, airway pressure far greater than pleural pressure (ie, high transpulmonary pressure) is required to induce lung injury. On the contrary, when very high airway pressure is applied, pressure measured inside the esophagus reflects only a transmitted pressure and the esophagus is not dilated but is instead compressed from outside. For this reason, high intrathoracic pressures are not likely to stress the anastomosis. As Carron highlighted in his letter to the Journal, swallowing air and the resulting gastric insufflation probably represent the main threat for anastomosis during NIV, as a positive transesophageal pressure may develop. The device used to provide ventilation in the current article was a laryngeal mask, which is less likely to induce gastric insufflation compared with face mask, the standard device for NIV. To confirm the safety of NIV after esophagectomy, we believe that future clinical trials should focus increasing pressure inside the esophagus during NIV when delivered by face mask.

References

Raman V. .MacGlaflin C.E. .Erkmen C.P. . Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model. Chest. 2015;147:356-361 [PubMed]journal. [CrossRef] [PubMed]
 
Yoshida T. .Uchiyama A. .Matsuura N. .Mashimo T. .Fujino Y. . Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury. Crit Care Med. 2012;40:1578-1585 [PubMed]journal. [CrossRef] [PubMed]
 
Carron M. . Safety considerations regarding noninvasive positive pressure ventilation following esophagectomy. Chest. 2015;147:e120- [PubMed]journal
 
Ho-Tai L.M. .Devitt J.H. .Noel A.G. .O’Donnell M.P. . Gas leak and gastric insufflation during controlled ventilation: face mask versus laryngeal mask airway. Can J Anaesth. 1998;45:206-211 [PubMed]journal. [CrossRef] [PubMed]
 

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References

Raman V. .MacGlaflin C.E. .Erkmen C.P. . Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model. Chest. 2015;147:356-361 [PubMed]journal. [CrossRef] [PubMed]
 
Yoshida T. .Uchiyama A. .Matsuura N. .Mashimo T. .Fujino Y. . Spontaneous breathing during lung-protective ventilation in an experimental acute lung injury model: high transpulmonary pressure associated with strong spontaneous breathing effort may worsen lung injury. Crit Care Med. 2012;40:1578-1585 [PubMed]journal. [CrossRef] [PubMed]
 
Carron M. . Safety considerations regarding noninvasive positive pressure ventilation following esophagectomy. Chest. 2015;147:e120- [PubMed]journal
 
Ho-Tai L.M. .Devitt J.H. .Noel A.G. .O’Donnell M.P. . Gas leak and gastric insufflation during controlled ventilation: face mask versus laryngeal mask airway. Can J Anaesth. 1998;45:206-211 [PubMed]journal. [CrossRef] [PubMed]
 
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