[Epidural anesthesia with noninvasive positive pressure ventilation in a patient with compromised respiratory...

We report successful epidural anesthetic management in a patient with severely impaired respiratory function. A 47-year-old woman (39 kg, 158 cm) was scheduled for right thoracoplasty. She had undergone fenestration surgery for empyema three months previously and required supplemental oxygen. Her vital capacity was 700 ml and forced expiratory volume in one second was 650 ml, indicating a severe restrictive pulmonary disorder. Hence, in order to avoid general anesthesia with tracheal intubation, we opted for epidural anesthesia. An epidural catheter was inserted in the T6-7 interspace and a bolus of 4.5 ml each of 1% mepivacaine and 1% ropivacaine was injected through the epidural catheter after a test dose. Ten minutes after the injection, the patient complained of difficulty in breathing and her oxygen saturation fell from 96% to 93%. We applied noninvasive positive pressure ventilation (NPPV) via a nasal mask to the patient, with the ventilator set at spontaneous/timed mode with inspiratory/expiratory positive airway pressure of 14/5 cmH2O. With this therapy, the patient's respiratory symptoms subsided rapidly and we could maintain adequate oxygenation and ventilation throughout the operation. We believe that epidural anesthesia with NPPV is a useful option for patients with compromised respiratory function.