Impaired Upper Airway Integrity by Residual Neuromuscular Blockade: Increased Airway Collapsibility and Blunted Genioglossus Muscle Activity in Response to Negative Pharyngeal Pressure

Herbstreit, Frank; Peters, Jürgen; Eikermann, Matthias

doi:10.1097/aln.0b013e31819faa71

Cited by 103 publications

(31 citation statements)

References 39 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…To translate the observed findings to an increased airway stability, formal measurements of airway patency (upper airway closing pressure) are required. An increased upper airway closing pressure (to less negative values) has been demonstrated after neuromuscular blockade, partly due to an impaired response of the genioglossus muscle to negative pressure and is associated with a less stable airway 45 .…”

Section: Discussionmentioning

confidence: 99%

Ketamine Activates Breathing and Abolishes the Coupling between Loss of Consciousness and Upper Airway Dilator Muscle Dysfunction

Eikermann

Grosse-Sundrup

Zaremba³

et al. 2012

Anesthesiology

Self Cite

114

View full text Add to dashboard Cite

Background Procedural sedation is frequently performed in spontaneously breathing patients but hypnotics and opioids decrease respiratory drive and place the upper airway at risk for collapse. Methods In a randomized, controlled, cross-over, pharmaco-physiological study in 12 rats, we conducted acute experiments to compare breathing, and genioglossus electromyogram activity at equianesthetic concentrations of ketamine, a non-competitive N-methyl-D-aspartate receptor antagonist that combines potent analgesic with hypnotic action effects, versus propofol. In 10 chronically instrumented rats resting in a plethysmograph, we measured these variables as well as electroencephalography during 5 conditions: quiet wakefulness, non-rapid-eye-movement sleep, rapid eye movement sleep, low-dose (60mg/kg intraperitoneally) and high-dose ketamine anesthesia (125mg/kg intraperitoneally). Results Ketamine anesthesia was associated with markedly increased genioglossus activity (1.5 to 5-fold higher values of genioglossus electromyogram) compared with sleep and propofol induced unconsciousness. Plethysmography revealed a respiratory stimulating effect: higher values of flow rate, respiratory rate, and duty-cycle (effective inspiratory time, 1.5-to-2-fold higher values). During wakefulness and normal sleep, the beta (f=6.51, p=0.04) electroencephalogram power spectrum was an independent predictor of genioglossus activity, indicating an association between electroencephalographic determinants of consciousness and genioglossus activity. Following ketamine administration, electroencephalogram power spectrum and genioglossus electroencephalogram was dissociated (p=0.9 for the relationship between delta/theta power spectrum and genioglossus electromyogram). Conclusions Ketamine is a respiratory stimulant that abolishes the coupling between loss-of-consciousness and upper airway dilator muscle dysfunction in a wide dose-range. Ketamine compared with propofol might help stabilize airway patency during sedation and anesthesia.

show abstract

Section: Discussionmentioning

confidence: 99%

Ketamine Activates Breathing and Abolishes the Coupling between Loss of Consciousness and Upper Airway Dilator Muscle Dysfunction

Eikermann

Grosse-Sundrup

Zaremba³

et al. 2012

Anesthesiology

Self Cite

114

View full text Add to dashboard Cite

show abstract

“…The lingering effects of NMBAs can thus have profound and potentially serious consequences on airway patency. Upper airway dilator muscles counter-act the negative intraluminal pressure generated by the respiratory pump muscles to maintain airway patency during inspiration [40, 41]. With residual paralysis however, the efficacy of these dilator muscles is markedly impaired, enough to significantly increase airway collapsibility [40, 41].…”

Section: Residual Paralysis and Outcomesmentioning

confidence: 99%

“…Upper airway dilator muscles counter-act the negative intraluminal pressure generated by the respiratory pump muscles to maintain airway patency during inspiration [40, 41]. With residual paralysis however, the efficacy of these dilator muscles is markedly impaired, enough to significantly increase airway collapsibility [40, 41]. By measuring pharyngeal and pulmonary function, we observed that upper airway obstruction occurs commonly during inspiration, even at minimal levels of neuromuscular block [40].…”

Section: Residual Paralysis and Outcomesmentioning

confidence: 99%

Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery?

Farhan

Moreno-Duarte

McLean

et al. 2014

Curr Anesthesiol Rep

Self Cite

View full text Add to dashboard Cite

Neuromuscular blocking agents are used to facilitate tracheal intubation in patients undergoing ambulatory surgery. The use of high-dose neuromuscular blocking agents to achieve muscle paralysis throughout the case carries an increased risk of residual post-operative neuromuscular blockade, which is associated with increased respiratory morbidity. Visually monitoring the train-of-four (TOF) fade is not sensitive enough to detect a TOF fade between 0.4 and 0.9. A ratio <0.9 indicates inadequate recovery. Quantitative neuromuscular transmission monitoring (e.g., acceleromyography) should be used to exclude residual neuromuscular blockade at the end of the case. Residual neuromuscular blockade needs to be reversed with neostigmine, but it’s use must be guided by TOF monitoring results since deep block cannot be reversed, and neostigmine administration after complete recovery of the TOF-ratio can induce muscle weakness. The development and use of new selectively binding reversal agents (sugammadex and calabadion) warrants reevaluation of this area of clinical practice.

show abstract

“…Postoperative residual curarization was also identified as one of the risk factors for upper airway obstruction, as it typically impaired the upper airway dilator muscle strength, while preserving inspiratory muscle function. [3738]…”

Section: Discussionmentioning

confidence: 99%

Negative pressure pulmonary edema with laryngeal mask airway use: Recognition, pathophysiology and treatment modalities

Vandse

Kothari

Tripathi

et al. 2012

Int J Crit Illn Inj Sci

View full text Add to dashboard Cite

Negative pressure pulmonary edema (NPPE) following the use of the laryngeal mask airway (LMA) is an uncommon and under-reported event. We present a case of a 58-year-old male, who developed NPPE following LMA use. After biting vigorously on his LMA, the patient developed stridor upon emergence, with concurrent appearance of blood-tinged, frothy sputum and pulmonary edema. He subsequently required three days of mechanical ventilation. After discontinuation of mechanical ventilation the patient continued to require additional pulmonary support using continuous positive airway pressure, with a full facemask, to correct the persistent hypoxemia. His roentgenographic findings demonstrated an accelerated improvement with judicious administration of intravenous furosemide.

show abstract

Impaired Upper Airway Integrity by Residual Neuromuscular Blockade: Increased Airway Collapsibility and Blunted Genioglossus Muscle Activity in Response to Negative Pharyngeal Pressure

Cited by 103 publications

References 39 publications

Ketamine Activates Breathing and Abolishes the Coupling between Loss of Consciousness and Upper Airway Dilator Muscle Dysfunction

Ketamine Activates Breathing and Abolishes the Coupling between Loss of Consciousness and Upper Airway Dilator Muscle Dysfunction

Residual Paralysis: Does it Influence Outcome After Ambulatory Surgery?

Negative pressure pulmonary edema with laryngeal mask airway use: Recognition, pathophysiology and treatment modalities

Contact Info

Product

Resources

About