Characteristics and surgical management of respiratory complications accompanying pathologic lesions of the brain stem.

Three life-threatening respiratory complications are regularly encountered in patients who survive the initial insult from a diffuse brain stem lesion--central alveolar hypoventilation, upper airway obstruction, and aspiration pneumonitis. From treating 13 patients who did survive, a surgical plan for managing the respiratory sequelae of such injuries has evolved and consists of: 1)Diaphragm pacing to correct hypoventilation; 2) tracheostomy for bypass of the upper airway obstruction; 3) gastrostomy for bypass of the impaired structures of swallowing; 4) surgical closure of the larynx to prevent aspiration. All 13 patients manifested central apnea, which was controlled in five by bilateral phrenic nerve stimulation and in eight by unilateral stimulation. All patients required tracheostomy to provide an airway for artificial ventilation and for secretion removal. In ten patients aspiration necessitated gastrostomy. The spontaneous recovery of the ability to swallow allowed closure of the gastrostoma in three but in others aspiration remained a serious complication. One patient died of massive aspiration after discharge from the hospital. Three patients had surgical closure of the larynx to prevent aspiration. Seven patients are alive; six of them are leading productive lives, though several have severe disability due to paresis or ataxia. Six died after discharge from the hospital. Three deaths were not related to the basic problem but the three others may have been.