LINEBURG


<< . .

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prevent recurrence Thoracoscopy

SUCCESS FAILURE

Thoracoscopy to Tube
prevent recurrence thoracostomy

FAILURE
SUCCESS
Catheter
aspiration


Stable PP
> 15%


Observation Stable pneumo Tube
PNEUMOTHORAX Unstable pneumo
and O2 < 15% thoracostomy


Stable SP
> 15%


Tube
thoracostomy
SUCCESS FAILURE

Thoracoscopy to Thoracoscopy
prevent recurrence

Figure 4.8 Acute management of pneumothorax.


with hypoventilation and hypoxia primarily during sleep.184
Miscellaneous respiratory disorders
These patients have negligible or absent ventilatory sensitivity
Tracheal stenosis to hypoxia and hypercapnia.185 If left untreated, chronic hypoxia
can lead to pulmonary hypertension and, eventually, cor pulmo-
Tracheal stenosis can be idiopathic or secondary to previous
nale. Although the etiology is unknown, there is considerable
trauma. In nonpregnant patients, signs of upper airway obstruc-
evidence to support a genetic mechanism.186,187 The diagnosis
tion are absent until 75% narrowing occurs. However, during
of CCHS is one of exclusion. Most patients require lifelong venti-
pregnancy, airway engorgement can increase the severity of pre-
existing tracheal stenosis.180 Parturients with uncorrected steno- latory support during sleep, while a few patients require such
support 24 hours a day. Options for ventilatory support include
sis will not tolerate the increased ventilatory demands of labor.
positive-pressure ventilation via tracheostomy, positive-pressure
Sutcliffe et al. described a patient with uncorrected tracheal ste-
ventilation via nasal or face mask, bilevel positive airway pressure
nosis who underwent uneventful C/S under regional anesthesia
(BiPAP), or diaphragmatic pacing.184
but died postpartum from airway obstruction.181
Endogenous progesterone levels are raised during pregnancy.
Management options for tracheal stenosis include balloon dila-
Although progesterone is a respiratory stimulant that increases
tion, tracheal stenting, laser excision, or tracheal resection with
reconstruction.182 Persistent obstruction despite the aforemen- central chemoreceptor sensitivity, no improvement in ventilatory
response to hypercapnia has been demonstrated during preg-
tioned interventional methods may warrant tracheostomy.
nancy.188 Of all the options for ventilatory support, diaphragmatic
Regional anesthesia avoids instrumentation of the trachea and
has been utilized for labor analgesia.180 Mask-inhalation induc- pacing has been used successfully during pregnancy, despite the
potential for diaphragmatic impairment from uterine growth.
tion with sevoflurane has been used for operative delivery in a
parturient with tracheal stenosis.183 However, parturients must be closely monitored with regular poly-
somnograms to assess the need for adjustments in pacer settings.
The use of epidural anesthesia for C/S has been described in
Congenital central hypoventilation syndrome
parturients with CCHS treated with diaphragmatic pacing. In such
patients, all central nervous system depressants must be avoided.
Congenital central hypoventilation syndrome (CCHS) stems
Furthermore, following C/S, incisional pain often prevents the use
from failure of autonomic control of breathing and manifests

94
Chapter 4


Summary
of diaphragmatic pacing during which time BiPAP ventilation is
utilized until diaphragmatic pacing can be resumed.
Respiratory disorders in pregnancy have the potential to worsen
with the physiologic and hormonal stresses that occur. It is
Pulmonary lymphangioleiomyomatosis important for obstetric anesthesiologists to see these women
early in pregnancy and to review any special investigations that
Pulmonary lymphangioleiomyomatosis (LAM) is characterized
have been performed. Timely consultation with pulmonologists
by the hamartomatous proliferation of smooth muscle of the
and perinatologists is important in providing the best anesthetic
pulmonary bronchioles, arterioles, and lymphatic vessels result-
care to pregnant women with pulmonary disease.
ing in cystic degeneration of lung tissue with variable progressive
loss of pulmonary function.189 Rupture of peripheral lung cysts
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