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Koyama2020 PDF
Koyama2020 PDF
latory mechanics in patients with obesity is reduced functional residual functional residual capacity (FRC), high closing-capacity-
capacity (FRC). Thus, increasing FRC and oxygen reserves is an important to-FRC ratio, increased metabolic demand, and greater oxygen
step to improve oxygenation and prevent oxygen desaturation in these in- consumption.9–12 These physiological properties are associated
dividuals. Head-up position, use of apneic oxygenation, noninvasive posi- with rapid decrease in oxygen saturation during apnea in morbidly
tive pressure ventilation, and high-flow nasal cannula help increase FRC obese individuals. Furthermore, previous reports described that
and oxygen reserves, resulting in improved oxygenation and prolonged obesity is one of the independent risk factors for difficult air-
safe apnea period. Furthermore, significantly higher incidence of difficult ways.9,13 Accordingly, morbidly obese patients are likely to be
mask ventilation is common in morbidly obese individuals. Supraglottic hypoxic, and thus, ventilatory strategies to prevent hypoxic epi-
airway devices establish effective ventilation in patients with difficult air- sodes in these patients during ECT are required. Even for an-
ways. Thus, the use of supraglottic airway devices is strongly recom- esthesiologists, anesthetic management in morbidly obese
mended in these patients. Conversely, because muscle fasciculation patients during ECT can be challenging. Consequently, practi-
induced by depolarizing neuromuscular blocking agents markedly in- tioners who perform anesthetic management of morbidly obese
creases oxygen consumption, especially in individuals with obesity, the patients undergoing ECT should have sufficient knowledge regard-
use of nondepolarizing neuromuscular blocking agents may contribute to ing their physiological properties to protect patients from reaching a
better oxygenation in morbidly obese patients during ECT. critical status.
Key Words: ECT, morbidly obese patient, preoxygenation, In this review, we propose effective anesthetic techniques to pre-
head-up position, supraglottic airway devices vent oxygen desaturation in morbidly obese patients during ECT.
(J ECT 2020;36: 161–167)
RESPIRATORY PHYSIOLOGY IN INDIVIDUALS
WITH OBESITY
P revious studies and meta-analysis have revealed that there is a
significantly positive association between depression and obe-
sity as commonly co-occurring medical conditions.1–4 Furthermore,
Patients with obesity show impaired respiratory physiology,
including reduced FRC, inspiratory capacity, vital capacity, de-
it has also been shown that depression is positively associated with creased respiratory compliance, increased airway resistance, and
metabolic diseases such as hyperlipidemia, type 2 diabetes, and greater oxygen consumption.9–12 Among these physiological
hypertension.4 In addition, the rate of obesity worldwide has properties, FRC, which serves as an oxygen reserve during apnea,
nearly tripled since 1975.5 In 2016, 39% of adults were over- can be increased with certain interventions, described in the fol-
weight (body mass index [BMI] > 25 kg/m2) and 13% were obese lowing sections. In pulmonary function test, FRC is defined as
(BMI > 30 kg/m2).5 Furthermore, the rate of morbidly obese the volume of air present in the lungs at the end of passive expiration.
(BMI > 40 kg/m2) patients among individuals with obesity is in- Obesity severely impairs pulmonary function mainly due to the
creasing fast.6 Taken together, the number of morbidly obese pa- decrease in FRC secondary to cephalad diaphragmatic displace-
tients requiring ECT is increasing. ment, resulting in decrease in oxygen reserves.14 This is likely
Anesthetic management for ECT has not changed since the due to the increased fat tissue in the chest wall, abdominal wall,
late 1950s. Preoxygenation is usually applied in supine position and abdomen that compresses the diaphragm and lungs in individ-
using a face mask with 100% oxygen, and oxygenation is maintained uals with obesity. Furthermore, FRC is significantly reduced in
supine position than in sitting position, because of further eleva-
tion of the diaphragm and increased pulmonary blood volume.15
From the *Department of Anesthesia, Nippon Koukan Hospital, Kawasaki; Therefore, FRC is an important factor that maintains and improves
†Department of Anesthesiology, Tokai University School of Medicine, Isehara; oxygenation and can be increased in clinical settings, especially to
‡Department of Anesthesiology, Tokyo Women's Medical University, Tokyo;
and §Department of Anesthesiology, Gunma University Graduate School of treat individuals with obesity.
Medicine, Maebashi, Japan.
Received for publication October 6, 2019; accepted December 3, 2019.
Reprints: Yukihide Koyama, MD, PhD, Department of Anesthesia, Nippon
PREOXYGENATION
Koukan Hospital, 1-2-1 Koukan-dori, Kawasaki-ku, Kawasaki-shi, The aim of preoxygenation before anesthesia induction is to
210-0852, Kanagawa Prefecture, Kawasaki, Japan maximize intrapulmonary oxygen reserves and prevent earlier onset
(e‐mail: yukihidekoyama1008@gmail.com).
Conflicts of interest and sources of funding: none declared.
of oxygen desaturation. Considering the physiological properties
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. of morbidly obese individuals, some modified techniques for
DOI: 10.1097/YCT.0000000000000664 preoxygenation should be considered to allow prolonged apnea
162 www.ectjournal.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.
oxygenation and prolongs the safe apnea period in patients with of HFNC in obese patients during ECT are required to support
obesity. Various techniques for supplying oxygen during apnea our contention.
have been described, including the use of nasopharyngeal airways, To the best of our knowledge, there are no reports investigat-
standard nasal cannula prongs, high-flow nasal cannula (HFNC), ing the efficacy of preoxygenation with NPPVand apneic oxygen-
and modified tracheal tubes in individuals with obesity.30 Oxygen ation for ECT anesthesia in morbidly obese patients. However,
insufflation from nasal cavity immediately after preoxygenation considering the diminished respiratory function of morbidly obese
significantly delayed the onset of desaturation in morbidly obese patients, preoxygenation with these techniques, which increase FRC
patients during the subsequent apnea.31 This apneic oxygenation and oxygen reserves, and promote denitrogenation and CO2 wash-
technique by supplying oxygen via the nasal cavity during apnea out, will be effective in morbidly obese patients during ECT. Fur-
can be easily applied without any specific apparatus. thermore, the use of these techniques in head-up position will be
much more effective in these individuals.
FIGURE 3. A and B, Images represent the main body of HFNC (AIRVO 2; Fisher & Paykel, Auckland, NewZealand) and its specific nasal
cannula, respectively.
© 2020 Wolters Kluwer Health, Inc. All rights reserved. www.ectjournal.com 163
FIGURE 4. Examples of SGAs are shown. A–C, Images represent ProSeal laryngeal mask airway (PLMA; Teleflex, Morrisville, NC), i-gel
(Intersurgical Ltd, Workingham, England), and Aura-i (Ambu Ltd, St Ives, Cambridgeshire, United Kingdom), respectively.
complications. In difficult mask ventilation scenarios, SGAs have with obesity.50 Repeated tracheal intubation for short intervals
been effective for rescue ventilation.42,43 Koyama et al8 reported can cause airway complications such as sore throat, swelling, and
that mechanical ventilation with SGA was considerably effective even bleeding secondary to airway trauma.50 In addition, because tra-
in morbidly obese patients with difficult mask ventilation during cheal intubation is commonly associated with greater hemodynamic
ECT. Furthermore, Sinha et al44 demonstrated that mechanical responses, this procedure may impose an increased risk of cardio-
ventilation using SGA after anesthesia induction was more effec- vascular and cerebrovascular complications during and after ECT
tive in increasing oxygen reserves and improving oxygenation treatment in individuals with obesity. Furthermore, Hutchens et al51
than conventional mask ventilation in morbidly obese patients un- reported that ECT treatment with repeated tracheal intubation re-
dergoing elective surgery. sulted in critical airway complications. Thus, repeated tracheal in-
Maintaining appropriate arterial CO2 tension is important in tubation for subsequent ECT sessions is not recommended.
ECT anesthesia, because hypocapnia immediately before electrical However, in case of failure of ventilation with SGAs, physicians
current application is beneficial to ensure adequate seizure duration.45 should be prepared for tracheal intubation and surgical airway access
Accordingly, hyperventilation immediately before electrical stimula- as emergency airway securing. Although controversial,39 obesity is
tion is recommended by the American Psychiatric Association.46 In thought to be associated with difficult intubation.52 Thus, in addition
a previous report from Nishihara et al,47 arterial CO2 tension was to conventional Macintosh laryngoscope, if available, channeled
found to be significantly lower in patients under mechanical ven- or nonchanneled blade-type videolaryngoscope (Fig. 5) should
tilation with SGA throughout the procedure than in patients under be prepared for emergency tracheal intubation, because these are
conventional manual mask ventilation, and seizure duration was more effective for difficult tracheal intubation due to difficult
significantly shorter in patients with face mask ventilation than laryngoscopy.53–55 Unlike the Macintosh laryngoscope, these do
in patients with SGA ventilation. Furthermore, controlled ventila- not require optimal alignment of the three anatomic axes—the
tion using SGA can enhance the effect of ECT treatment, com- oral, pharyngeal, and tracheal axes—to see the glottis. Thus, these
pared with uncontrolled ventilation using a conventional face scopes enable the operator to identify the glottic opening on the
mask.48 Hypoxia and/or hypercapnia induced by inadequate ven- monitor and to easily advance the tracheal tube into the trachea.
tilation produced hypertension and tachycardia after seizure,49 Furthermore, these can contribute to attenuation of hemodynamic
which may lead to cardiovascular or cerebrovascular events, espe- responses to tracheal intubation.56–58
cially in morbidly obese patients.
The use of SGAs is one among the major solutions for diffi-
cult mask ventilation and oxygen desaturation in morbidly obese MUSCLE RELAXANTS
individuals after anesthesia induction. In addition, hyperventilation The goal of providing muscle relaxants during ECT is to
and appropriate adjustment of end-tidal CO2 can be easily achieved reduce the risk of injury caused by convulsion and at the same
with SGAs.47 Furthermore, SGAs are currently easily available and time to allow for prompt recovery of spontaneous breathing after
their use is widely accepted in clinical settings. Thus, SGAs are seizure termination.
strongly recommended for airway management, especially in mor-
bidly obese patients during ECT. Depolarizing or Nondepolarizing Neuromuscular
Blocking Agents?
Tracheal Intubation Succinylcholine chloride (SCC), a depolarizing neuromus-
Tracheal intubation is not necessary in most cases, because cular blocking agent, is commonly used as a muscle relaxant dur-
inadvertent regurgitations are extremely rare even in individuals ing ECT because of its short period of action.46 Sufficient muscle
164 www.ectjournal.com © 2020 Wolters Kluwer Health, Inc. All rights reserved.
FIGURE 5. A and B, Images represent nonchanneled blade-type, McGrath videolaryngoscope (Aircraft Medical Ltd, Edinburgh,
United Kingdom) and channeled blade type, Pentax AWS (Hoya, Tokyo, Japan), respectively.
relaxation to prevent injury during ECT can be achieved with 0.9 oxygenation and prolong the safe apnea period. Supraglottic airway
to 1.1 mg/kg SCC in most patients.59 devices can be strongly recommended in morbidly obese patients to
During ECT, oxygen consumption and CO2 production are avoid manual mask ventilation failure, improve oxygenation, and
increased not only due to seizure activity,60 but also due to fascic- prevent hypercapnia during ECT. Oxygen consumption caused by
ulation induced by SCC.49,61 Tang et al62 demonstrated that SCC SCC-related muscle fasciculation can be avoided with rocuronium,
induced significantly shorter period of safe apnea and longer recovery the effect of which can be rapidly reversed by sugammadex.
period from saturation to 97% than rocuronium—a nondepolarizing
neuromuscular blocking agent—in morbidly obese patients. This
is due to increased muscle oxygen consumption induced by SCC-
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