Measuring patients\' core body temperature during surgery is essential and commonly performed with an esophageal temperature probe. The probe must be placed in the lower third of the esophagus for accurate measurement. In this case report, we describe our experience of discovering an inadvertently malpositioned esophageal temperature probe in the right inferior lobar bronchus, which led to ventilation-related problems in a patient undergoing prostate surgery.

Pneumothorax is a potentially fatal complication in patients with acute respiratory distress syndrome (ARDS), presenting challenges in determining the optimal positive end-expiratory pressure (PEEP) level to prevent atelectasis without exacerbating the pneumothorax. This case report describes the successful application of transpulmonary pressure and electrical impedance tomography (EIT) at the bedside to guide PEEP selection in a patient with ARDS complicated by pneumothorax due to methicillin-resistant Staphylococcus aureus infection. By using minimal PEEP to maintain positive end-expiratory transpulmonary pressure and visualizing lung reopening with EIT, the optimal PEEP level was reaffirmed, even if traditionally considered high. The patient\'s condition improved, and successful weaning from the ventilator was achieved, leading to a transfer out of the intensive care unit. Clinical trial registration: https://clinicaltrials.gov/show/NCT04081142, identifier NCT04081142.

Patients with a Blom® tracheostomy tube (containing a cuff) can vocalize while on mechanical ventilation, which can significantly improve the patient\'s quality of life. This is brought by the purpose-built structure of the tracheostomy tube that allows the expiration to be expelled through the glottis. However, this characteristic may complicate the measurement of the patient\'s tidal volume, as most of the expiration does not return to the ventilator. Owing to the necessity of insertion of the speech cannula, which acts as an inner cannula, to enable patient vocalization, the air passage likely becomes constricted, thus increasing airway resistance. Difficulty in applying appropriate positive end-expiratory pressure (PEEP) and ventilator auto-triggering may also be problematic. Therefore, alveolar ventilation is predicted to decrease without adjusting the ventilation settings. Our experience using the Blom® tracheostomy tube revealed some problems, and we provide suggestions for patient management. We herein report on the experience of a patient having inserted the Blom® tracheostomy tube receiving mechanical positive pressure ventilation during vocal training.

UNASSIGNED: Atrial functional mitral regurgitation (AFMR) is an entity of mitral regurgitation (MR) in atrial fibrillation (AF) with dilated left atrium (LA) and/or normal left ventricular function. Transcatheter edge-to-edge mitral valve repair with MitraClip is reportedly an effective therapy for AFMR. However, performing MitraClip for patients with such condition is challenging because of its characteristic morphology.
UNASSIGNED: An 80-year-old man with permanent AF and severe MR was hospitalized for heart failure with preserved ejection fraction. On echocardiography, a marked dilation of the LA caused the anterior mitral leaflet to flatten along the mitral annulus (MA) plane. The posterior mitral leaflet was tethered towards the posterior left ventricle, thus producing a coaptation gap of 6.5 mm between the leaflets. Given his high surgical risk, MitraClip therapy was performed, but leaflet grasping was difficult because of the notable coaptation gap. When positive end-expiratory pressure (PEEP) was applied by mechanical ventilation, the MA gradually decreased in diameter. Under 20 cm H2O of PEEP, the coaptation gap decreased to 0 mm, which finally enabled the grasping of the leaflets. The clip was deployed, thus leaving only mild MR. Thereafter, the patient had an uneventful clinical course.
UNASSIGNED: In patients with AFMR, the sagittal dilation of the MA and asymmetry in the tethering angles of the leaflets often produce a marked coaptation gap, which poses a challenge in MitraClip therapy. In our patient, the ventilator-assisted technique effectively reduced the coaptation gap between the leaflets, thus leading to successful results.

Because of a painful right-sided coxarthrosis a 57-year-old female patient underwent a cementless total arthroplasty under general anesthesia. Except for Asperger\'s syndrome and an occlusion of a vein in her left eye she stated no other diseases or complaints, especially no cardiac problems. Postoperatively she developed neurological symptoms of left-sided hemiparesis and hemihypesthesia. A cranial computer tomography was performed and a right-sided infarction of the thalamic region was found. A patent foramen ovale (PFO) and atrial septal aneurysm were detected 5 days later. The incidence of a PFO is given as 25% of the population. A paradoxical air embolism in the presence of a PFO is a feared complication in neurosurgical interventions in a semi-sitting or sitting position. Corpuscular emboli, such as bone, cement, fat or wound debris may be the reason for paradoxical embolisms in combination especially with partial or total hip replacement. The kind of embolism in the case described could not be clarified. Deep vein thrombosis or cardiac arrhythmia could be excluded. Therefore, it can be considered most likely that the operation site was the source of the embolism. The trigger for a paradoxical embolism is a reversal of the pressure difference between the right and left atria: normally the left atrial pressure exceeds the right atrial pressure by ca. 2-4 mm Hg, resulting possibly in a small clinically irrelevant left-to-right shunt. If the pulmonary arterial circulation is compromised and pulmonary vascular resistance increases, the pressure gradient between the left and right atria reverses and a right-to-left shunt can occur causing a paradoxical embolism. Positive end-expiratory pressure (PEEP) ventilation during anesthesia could be an important reason for a shunt reversal between the right and left atria and therefore favoring a paradoxical embolism but the pathophysiological role of PEEP has not yet been finally clarified.
Nach einem komplikationslosen totalen Hüftgelenkersatz mit einer zementfreien Prothese in Intubationsnarkose zeigte eine 57 Jahre alte Patientin postoperativ das neurologische Bild einer linksseitigen Hemiparese und Hemihypästhesie. Am ersten postoperativen Tag wurde mit einer kranialen Computertomographie (CCT) ein frischer rechtsseitiger Thalamusinfarkt diagnostiziert. Am sechsten postoperativen Tag konnte mittels transösophagealer Echokardiographie (TEE) ein mittelgroßes persistierendes Foramen ovale (PFO) mit Vorhofseptumaneurysma nachgewiesen werden. Die Inzidenz eines PFO wird in der Literatur mit 25 % angegeben. Eine paradoxe Luftembolie bei PFO ist eine gefürchtete Komplikation v. a. bei neurochirurgischen Operationen in halbsitzender oder sitzender Lagerung, während in der Gelenkersatzchirurgie korpuskuläre Emboli im Vordergrund stehen. Um welche Art von Embolus es sich im vorliegenden Fall handelte, konnte nicht geklärt werden. Da bei der Patientin weder eine tiefe Beinvenenthrombose noch Herzrhythmusstörungen vorlagen, kommt nur noch der Operationssitus als Embolusquelle infrage. Auslöser einer paradoxen Embolie ist eine Umkehr der Druckdifferenz zwischen rechtem und linkem Vorhof als Folge einer Zunahme des pulmonalen Gefäßwiderstands. Ob, und wenn ja, welchen Beitrag die Beatmung mit positivem endexspiratorischem Druck (PEEP) dabei leistet, ist noch nicht abschließend geklärt.

BACKGROUND: Excessive dynamic airway collapse (EDAC) is an uncommon cause of high airway pressure during mechanical ventilation. However, EDAC is not widely recognized by anesthesiologists, and therefore, it is often misdiagnosed as asthma.
METHODS: A 70-year-old woman with a history of asthma received anesthesia with sevoflurane for a laparotomic cholecystectomy. Under general anesthesia, she developed wheezing, high inspiratory pressure, and a shark-fin waveform on capnography, which was interpreted as an asthma attack. However, treatment with a bronchodilator was ineffective. Bronchoscopy revealed the collapse of the trachea and main bronchi upon expiration. We reviewed the preoperative computed tomography scan and saw bulging of the posterior membrane into the airway lumen, leading to a diagnosis of EDAC.
CONCLUSIONS: Although both EDAC and bronchospasm present as similar symptoms, the treatments are different. Bronchoscopy proved useful for distinguishing between these two entities. Positive end-expiratory pressure should be applied and bronchodilators avoided in EDAC.

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