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| LETTER TO THE EDITOR |
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| Year : 2018 | Volume
: 8
| Issue : 1 | Page : 60-61 |
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NIV use for postpartum morbidly obese with pulmonary edema
Parikshit Singh1, Ram M Sharma2
1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Anaesthesiology and Critical Care, Military Hospital, Patiala, Punjab, India
| Date of Web Publication | 13-Apr-2018 |
Correspondence Address:
Dr. Parikshit Singh
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/joacc.JOACC_40_17
How to cite this article:
Singh P, Sharma RM. NIV use for postpartum morbidly obese with pulmonary edema. J Obstet Anaesth Crit Care 2018;8:60-1 |
Sir,
It is with great interest that we read your editorial on non-invasive ventilation (NIV) (Trikha A, Kumar AA. Non-invasive ventilation – An effective way of delivering air for two? J Obstet Anaesth Crit Care 2017;7:1-2). The observations made about the use of NIV in obstetric patients are pertinent. We would like to illustrate another use of NIV, namely, for postpartum patients experiencing difficult weaning.
A 36-year-old G2 (Gravida), A1 (Abortion) female patient with morbid obesity (108 kg, body mass index (BMI) 48 kg/m 2), chronic hypertension superimposed with pre-eclampsia, and obstructive sleep apnea (OSA) presented at 33 weeks of gestation for safe confinement. Subsequently, following a slow progress of labor with impending fetal distress, an emergency lower (uterine) segment Caesarean section (LSCS) was performed.
The patient was administered general anesthesia using a rapid sequence induction and intubation. A live male baby was delivered. The patient developed high blood pressure soon after intubation compounded further by surgical incision (maximum 180/110 mmHg), for which parenteral doses of nitroglycerin and esmolol were given as boluses. At the end of the surgery, the neuromuscular block was reversed and the trachea extubated. Soon after, she developed shallow breathing, peripheral cyanosis, and bilateral basal crackles on auscultation. The oxygen saturation dropped to 70% despite 100% oxygen being given by the face mask. The patient was quickly re-intubated on the operating table itself using intravenous propofol and succinylcholine. No difficulty was encountered during re-intubation despite obesity. Copious pink frothy secretions in the endotracheal tube (ETT) and high airway pressures were seen. Injection furosemide 40 mg i.v. bolus was given and the lung compliance improved. A central line and an arterial line were inserted in the right internal jugular vein and right radial artery, respectively, for invasive monitoring, and the patient was then shifted to intensive care unit (ICU) on ventilator. Arterial blood gas (ABG) showed severe respiratory acidosis (pH 7.14, PaCO2 81.7 mmHg, PO2 514.1 mmHg), central venous pressure (CVP) was 18 mmHg, and arterial BP was 180/120mmHg. Injection furosemide 40 mg i.v. was repeated along with morphine 3 mg i.v. The patient's condition improved gradually with mechanical ventilation and positive end expiratory pressure (PEEP). She was weaned off mechanical ventilation and extubated within 24 h.
Post-extubation, the patient, once again, developed tachypnea (50/min), desaturation (SpO2 65%), tachycardia (160/min), hypertension (176/118 mmHg), bilateral basal crepts, and depressed sensorium needing immediate re-intubation. Copious pink frothy secretions welled out of the ETT. After 30 min of positive pressure ventilation with PEEP, the secretions reduced. Bedside echocardiography showed left ventricular (LV) diastolic dysfunction with good contractility. Cardiac markers were negative for any acute coronary event. She was mechanically ventilated for next 36 h and gradually weaned off to spontaneous mode of ventilation. However, she still needed high-pressure support [Figure 1]. | Figure 1: Patient on spontaneous mode of ventilation with high pressure support
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On post-op day 3, she was extubated and put on intermittent NIV support using a face mask interface with pressure support 14 cm H2O, continuous positive airway pressure (CPAP) 6 cm H2O, and FiO2 0.4. She tolerated it well and was slowly weaned off NIV in the next 48 h.
Use of PEEP, diuretics, and opioids is considered the mainstay of therapy in acute pulmonary edema.[1] Difficulties arise when attempting to wean these patients off invasive ventilation. Compromised lung compliance owing to morbid obesity, OSA, and pregnancy prevents effective ventilation post-extubation and the chances of pulmonary edema looms large.[2] NIV helps overcome this spectre by reducing the work of breathing, maintaining oxygenation, reducing CO2 retention, and allowing patients to be weaned off the ventilator.[3] The risk of aspiration is 1 in 10,000 in peripartum women. However, NIV could still be used effectively in patients who are fully conscious and able to control their airway with adequate respiratory effort.[4]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Baird A. Acute Pulmonary Oedema: Management in General Practice. Aust Fam Physician 2010;39:910-4.  [ PUBMED] |
| 2. | Ungern-Sternberg BS, Regli A, Schneider MC, Kunz F, Reber A. Effect of obesity and site of surgery on peri-operative lung volumes. Br J Anaesth 2004;92:202-7. [ PUBMED] |
| 3. | Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med 2008;359:142-51. |
| 4. | Mazlan MZ, Ali S, Zainal Abidin H, Mokhtar AM, Ab Mukmin L, Ayub ZN, Nadarajan C. Non-invasive ventilation in a pregnancy with severe pneumonia. Respir Med Case Rep 2017;21:161-3. [ PUBMED] |
[Figure 1]
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