Effectiveness of Assisted Ventilation Supplemented by RTX and NPPV for the Prevention of Postoperative Respiratory Failure in a Patient with Severe COPD Undergoing Total Arch Replacement
症例は74歳,男性.以前より遠位弓部大動脈瘤を指摘されていたが,拡大傾向を認めたため手術目的に紹介入院となった.画像上遠位弓部大動脈に頭側に突出する最大径65mmの嚢状動脈瘤を認めた.また,入院時Hugh-Jones分類IV度の呼吸障害と気管支喘息を合併しており,呼吸機能検査で1秒量が初回時0.57l,再検時0.49lと低値で,Stage IVの最重症慢性閉塞性肺疾患(COPD)を認めた.本症例に対して待機的に弓部大動脈全置換術(TAR)を施行した.術後2日目に呼吸離脱を図ったが,呼吸不全が顕著となり陽・陰圧体外式人工呼吸器(respiratory therapy external:RTX)を装着し,その後BiPAPを用いた非侵襲的陽圧換気(non-invasive positive pressure ventilation:NPPV)と併用して再挿管を回避,周術期呼吸不全をのりきった.重症COPDを合併した症例に対するTAR後呼吸不全に対して,RTXとNPPVを併用した補助呼吸療法は有効であり,周術期管理に役立つと考えられた. A 74-year-old man with very severe chronic obstructive pulmonary disease (COPD) was scheduled for elective total arch replacement for a distal arch saccular aneurysm. Postoperative respiratory failure was anticipated because of a marked reduction in forced expiratory volume in one second (FEV_<1.0>- less than 0.5 l). Through median sternotomy, total arch replacement using selective cerebral perfusion was completed uneventfully. Postoperative respiratory condition was stable. Therefore, the patient was extubated on postoperative day 2 (POD 2). However, as the respiratory condition started getting worse, respiratory therapy external (RTX) was introduced to assist ventilation. Additionally, non-invasive positive pressure ventilation (NPPV) with BiPAP was used on POD 3 and management with both RTX and NPPV was continued during the remainder of the intensive care unit stay. As a result, we were able to avoid re-intubation. In conclusion, assisted ventilation supplemented by RTX and NPPV was useful for the prevention of postoperative respiratory failure in a patient with very severe COPD undergoing total arch replacement.
最重症COPD合併症例に対する弓部全置換術後に陽・陰圧体外式人工呼吸器(RTX)と非侵襲的陽圧換気(NPPV)が有効であった1例
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