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 Table of Contents  
Year : 2021  |  Volume : 41  |  Issue : 6  |  Page : 319-320

The successful application of high-flow nasal cannula for a patient who underwent vertebroplasty with severe pulmonary hypertension

Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan

Date of Submission29-Apr-2021
Date of Decision02-Jun-2021
Date of Acceptance18-Jun-2021
Date of Web Publication01-Nov-2021

Correspondence Address:
Dr. Chun-Chang Yeh
Department of Anesthesiology, Tri-Service General Hospital, National Defense, Medical Center, 325, Cheng-Gong Rd, Section 2, Neihu 114, Taipei
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmedsci.jmedsci_140_21

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How to cite this article:
Huang LY, Lai MF, Hung NK, Yeh CC. The successful application of high-flow nasal cannula for a patient who underwent vertebroplasty with severe pulmonary hypertension. J Med Sci 2021;41:319-20

How to cite this URL:
Huang LY, Lai MF, Hung NK, Yeh CC. The successful application of high-flow nasal cannula for a patient who underwent vertebroplasty with severe pulmonary hypertension. J Med Sci [serial online] 2021 [cited 2022 Dec 3];41:319-20. Available from: https://www.jmedscindmc.com/text.asp?2021/41/6/319/323750

Dear Editor,

In the press, the JAMA: High-Flow Nasal Cannula System, Not Just Another Nasal Cannula[1] introduced the application of high-flow nasal cannula (HFNC) as a choice for preoxygenation to reduce apnea duration. In our study, we used HFNC broadly and extended its advantage by applying it to a patient with severe pulmonary hypertension who received vertebroplasty surgery under high-flow nasal cannula.

An 86-year-old woman had been suffering from back pain for months and had a compression fracture of T10. The surgeon suggested vertebroplasty to relieve her painful condition. However, she had hypertension and diabetes with limited functional activity. The echocardiogram revealed severe tricuspid valve regurgitation with a pulmonary atrial pressure of 57 mmHg and an ejection fraction of 53%. She was put on treatment with apixaban 5 mg, spironolactone 25 mg, amlodipine 5 mg, valsartan 80 mg, bisoprolol 2.5 mg, amiodarone 400 mg, and digoxin 0.125 mg. Her vital signs showed a heart rate of 120–132 beats/min with atrial fibrillation, non-invasive blood pressure of 128/74 mmHg, and SpO2 84% in the operating room. Her ASA physical status was III. The surgeon was informed of the situation and managed it with adequate local anesthetics before the incision to decrease the intravenous anesthetic dose usage. She was placed in the prone position wearing the high-flow nasal cannula as preoxygenation until SpO2 97% under Optiflow THRIVE™ HFNO at 35 L/min. On induction with lidocaine 40 mg and i.v. propofol, we gave a target control infusion with continuous propofol until she was not responsive to verbal commands and closed her eyes. During the surgery (40 min), the patient was prone under the HFNC, and SpO2 was kept above 95%. During the operation, the mean blood pressure stayed above 70 mmHg and SpO2 stayed above 95%. After the surgery, the patient recovered under temporary HFNC in the postanesthesia care unit.

There are two key considerations for maintaining adequate oxygenation in this patient. First, pulmonary hypertension with right-sided heart failure makes the patient not tolerate room air, including the apnea time under intravenous anesthetics. Both desaturation and carbon dioxide retention could worsen her pulmonary hypertension and add further load on her heart. The HFNC provides continuous positive airway pressure, and because of insufflation ventilatory, carbon dioxide clearance occurs through gaseous mixing which flushes the dead spaces.[2] Some studies use this advantage on pulmonary hypertension patients during bronchoscopy.[3]

Second, the prone position made the ventilation difficult. It is impractical or poorly tolerated to recruit the lung with high airway pressure when it is desaturated while in the prone position, especially for older patients with a stiff cervical spine. However, the prone position may provide an alternative way to recruit the dorsal lung regions without high ventilatory pressures,[4],[5] which could induce superior alveolar ventilation. No matter which position is used, we should always refer to the rescue plan in situations such as desaturation or unstable vital signs, even while under HFNC.[6]

There were no available clinical trials in the literature relating to the use of HFNC in managing pulmonary hypertension patients under the prone position with intravenous anesthetics and without intubation. As Vella et al.[1] mentioned, the HFNC system could be routinely integrated into rescue algorithms for possible events of respiratory deterioration. Here, we provide practical clinical and surgical situations to use HFNC innovatively.

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.

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Conflicts of interest

  References Top

Vella MA, Pascual-Lopez J, Kaplan LJ. High-Flow Nasal Cannula System: Not Just Another Nasal Cannula. JAMA Surg 2018;153:854-5.  Back to cited text no. 1
Hermez LA, Spence CJ, Payton MJ, Nouraei SAR, Patel A, Barnes TH. A physiological study to determine the mechanism of carbon dioxide clearance during apnoea when using transnasal humidified rapid insufflation ventilatory exchange (THRIVE). Anaesthesia 2019;74:441-9.  Back to cited text no. 2
Upperman L, Gildea T, Galway U. Transnasal humidified rapid insufflation ventilatory exchange during bronchoscopy in severe pulmonary hypertension due to Gerbode defect. Respirol Case Rep 2020;8:e00519.  Back to cited text no. 3
Scaravilli V, Grasselli G, Castagna L, Zanella A, Isgrò S, Lucchini A, et al. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care 2015;30:1390-4.  Back to cited text no. 4
Dikmen Y, Esquinas AM. Prone position in nonintubated hypoxemic respiratory failure. New tool to avoid endotracheal intubation? J Crit Care 2015;30:1415.  Back to cited text no. 5
Bernhard M, Bax SN, Hartwig T, Yahiaoui-Doktor M, Petros S, Bercker S, et al. Airway Management in the Emergency Department (The OcEAN-Study)-A prospective single centre observational cohort study. Scand J Trauma Resusc Emerg Med 2019;27:20.  Back to cited text no. 6


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