A 75 year gentleman presented with positional dysnea at rest. He could not sleep in supine and left lateral position for the past 3 months. Only position he could sleep was right lateral position. Often he developed symptoms of pulmonary edema in the form of sudden orthopnoea and copious frothy sputum. Unaware of any facts presented to a local doctors and later referred to us. Obviously without any hesitation it was diagnosed as Left atrial Myxoma. ECHO substantiated our diagnosis. His coronary angio was normal. He was taken for emergency surgery. LA Myxoma was taken out by no touch technique (because it is highly friable and may get embolised) and mitral valve was repaired. This is relatively a simple surgery requires little patience. The twist in this surgery was post operative care. This man was in respiratory failure who was only depended on CO2 drive. During surgery bypass machine keeps pO2 around 300 mm Hg. This has knocked out his CO2 drive. We could not wean him from ventilator for 6 days. Trust me we gave all the possible respiratory and brain stimulants including in caffeine. We adjusted ventilator parameters to keep his co2high and PO2 around 60 -70 mm Hg. Many cap trials were given. Because of tachypnea his co2 usually got washed. Lastly we came with local innovative jugad. We increased the dead space of endotracheal tube, used rebreathing circuit locally assembled. With god’s grace he could be able to develop hyperaemic breaths and later resumed normal breathing. FIO2 was kept at lowest 20%. Finally we could extubated him. Thankfully tracheostomy was avoided. He was discharged on post op day 12. Now doing fine. Many a times in cardiac surgery interesting, surprising things takes place. This would be one among them. Hopefully many doctors may get our information of managing such cases. You all can share your experience in managing respiratory failures. Still in India respiratory stimulants are not available everywhere.
Consultant-Cardiac Surgery Adult