CHEST Guidelines-Response_chest

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The correspondence discusses the safety considerations regarding the use of Noninvasive Positive Pressure Ventilation (NPPV) following esophagectomy, particularly in relation to pressure tolerance at surgical anastomosis sites. Dr. Michele Carron acknowledges a study by Raman et al., which indicated that esophageal anastomoses can tolerate higher pressures than those experienced during NPPV, ostensibly ensuring safety post-esophagectomy. However, Dr. Carron cautions against using pressures above 20 cm H₂O due to potential risks like gastric insufflation and consequent complications such as decreased venous outflow, vascular congestion, and possible ischemic effects at the anastomosis site.<br /><br />Dr. Carron further notes variability in pressure tolerance was found in the study, with ex vivo models showing lower tolerance levels, possibly due to factors like tissue ischemia after explantation. She emphasizes that careful management, including nasogastric decompression and cautious application of NPPV pressures, is necessary to avoid complications like pulmonary aspiration and pneumonia.<br /><br />In response, Dr. Cherie P. Erkmen and Vignesh Raman acknowledge Dr. Carron’s points and reiterate findings from their study using a porcine model, where esophageal pressures were relatively low (5-15 cm H₂O) even at higher supralaryngeal airway pressures. They report a wide safety margin between these pressures and those that could disrupt anastomoses. They agree with Dr. Carron’s caution regarding gastric insufflation and advocate for additional measures such as nasogastric tube use and pressure minimization to prevent aspiration and other complications.<br /><br />Both parties agree that further human studies are necessary to conclusively determine the safety and parameters for NPPV use post-esophagectomy. They stress the importance of continued caution and tailored management in clinical practice to mitigate potential risks effectively.

Keywords

Noninvasive Positive Pressure Ventilation

NPPV

esophagectomy

pressure tolerance

anastomosis site

gastric insufflation

nasogastric decompression

pulmonary aspiration

human studies

clinical practice