Respiratory Failure during BIS-Guided Sedation in a Patient with Relapsing Polychondritis: A Case Report

Abstract

Relapsing polychondritis (RP) is a rare autoimmune disorder that causes inflammation and deterioration of cartilaginous structures such as the ears, nose, joints and laryngotracheobronchial tree. A 42-year-old man receiving treatment for RP underwent open reduction and internal fixation of a femur fracture under spinal anesthesia and with sedation by propofol and remifentanil. The level of sedation was monitored via a bispectral index (BIS), and maintained at between 60 and 80. At the end of the operation, he lost consciousness and displayed weak respiratory effort. During mask ventilation, the patient was judged to have respiratory failure due to high end-tidal CO₂ (EtCO₂) concentration and respiratory acidosis in an arterial-blood-gas analysis (ABGA). Ventilation through a properly inserted laryngeal-mask-airway or endotracheal intubation were impossible; instead, a surgical tracheotomy was performed. After recovering from respiratory failure with ventilatory support in the intensive care unit (ICU), he experienced the same symptoms three more times, requiring ventilatory support. He was discharged with bilevel positive-airway-pressure (BiPAP), after successful adaptation.

Keywords: airway; bispectral index; relapsing polychondritis; respiratory failure; sedation; spinal anesthesia.

Figure 1

Preoperative chest radiography shows diffuse peribronchial cuffing in both lungs, with marked narrowing trachea, suggesting known relapsing polychondrits, and healed fracture at Rt. 8,9th and Lt. 8th rib.

Figure 2

(A) CT shows subglottic stenosis at cricoid level with short-axis diameter 4.63 mm. (B) Calcification and anterolateral wall thickening of tracheobronchial tree (arrow) and resulting luminal narrowing. (C) Tracheobronchial tree shows irregular narrowing of the lumen and marked diffuse luminal-narrowing of left mainstem bronchus.