Biedler A, Mertzlufft F, Feifel G
Klinik für Anaesthesiologie und Intensivmedizin der Universitätskliniken des Saarlandes.
Anasthesiol Intensivmed Notfallmed Schmerzther. 1995 Jun;30(4):257-60. doi: 10.1055/s-2007-996487.
Boerhaave's syndrome (Hermann Boerhaave, 1724 [5]) stands for the atraumatic spontaneous rupture of the oesophagus, and still represents a life-threatening situation. Contrary to the surgical approach, the anaesthesiological management has been largely neglected so far.
The present case report introduces a patient requiring surgical therapy due to a belatedly diagnosed rupture of the oesophagus. In agreement with the surgeon, endotracheal intubation was performed using a single-lumen oral Woodbridge tube. During left thoracotomy, artificial ventilation sometimes obstructed the surgeons. Following a life-threatening intrathoracic venous bleeding (after additional right thoracotomy), the situation became almost adverse, since the surgeon could not stop the bleeding due to the movement of the lungs. Ventilation was therefore stopped. The oxygen supply was provided 20 min by application of the so-called apnoeic oxygenation, first described in 1908 by the German surgeon Franz Volhard (15). Using the filled 2.5l reservoir bag of the circle circuit as the oxygen source (CPAP 10 cm H2O), oxygenation was maintained by refilling the bag after its volume had been decreased due to the patient's ongoing O2 consumption. Starting with an initial paO2 value of only 400mmHg (despite pAO2 approximately 670 mmHg, i.e. intrapulmonary right-left shunt of approx. 10-15%), the paO2 declined to 100 mmHg during the 20 min of apnoeic oxygenation (i.e. a drop by 15 mmHg per minute), whereas arterial pCO2 increased by 50 mmHg to a value of 90 mmHg, as stated recently in literature [18]). No relevant changes of ECG, heart rate, blood pressure and partial arterial oxygen saturation (pulse oxymeter) occurred.
During thoracic operations adverse situations may arise from the two antipodes artificial ventilation and acceptable surgical access. Alternative respiratory techniques, e.g. one-lung anaesthesia and/or high-frequency jet ventilation, are not always applicable, although the present case report indicates that a double lumen tube should be recommended. However, the clinical use of oxygenation by apnoeic oxygenation is a useful measure that can be realised in a simple and safe manner. The present case report may help to consider this particular alternative also during thoracic surgery (no influence of FRC size on pAO2 decrease). If applied correctly, apnoeic oxygenation obviously increases both the flexibility of the anaesthesist and patient safety, and additionally provides the ability of safe acting in clinical routine settings as well as during emergencies. In summary, knowledge of this technique of oxygenation seems to be an integral part of serious anaesthesiological education and clinical management.
