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• W2070391783 abstract "To the EditorI read with great interest the article by Raman et al1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar in a recent issue of CHEST(February 2015) that evaluated the pressure tolerance of esophagectomy anastomosis ex vivo and in vivo in a pig model in comparison with esophageal pressure during noninvasive positive-pressure ventilation (NPPV). The authors showed that anastomosis can tolerate higher pressures than those transmitted to the esophagus during NPPV, thus demonstrating the safety of NPPV after esophagectomy.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Despite these data, however, in the clinical setting caution is necessary for several reasons when using pressures > 20 cm H2O during NPPV after esophagectomy.First, the authors found significant variability in pressure tolerance using ex vivo and in vivo models.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In their study, the lowest pressure tolerated by ex vivo anastomoses before leakage was 21 cm H2O.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google ScholarSecond, the risk of gastric insufflation during NPPV increases with pressure > 20 cm H2O.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Even if a pressure of ≤ 15 cm H2O is considered safe, a pressure of 15 to 20 cm H2O is also acceptable for preventing gastric insufflation during NPPV.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar During NPPV, the ventilation volume is distributed between the lungs and stomach, depending on the respiratory system resistance and the esophageal sphincter pressure.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar The resting upper esophageal sphincter pressure is lower in elderly individuals compared with young people (24 ± 9 mm Hg vs 42 ± 14 mm Hg,P < .001).3Amaris M Dua KS Naini SR Samuel E Shaker R Characterization of the upper esophageal sphincter response during cough.Chest. 2012; 142: 1229-1236Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Furthermore, the protective function of the lower esophageal sphincter is generally lost after esophagectomy.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In clinical esophageal surgery, postoperative gastric distention not only may cause decreased venous outflow and vascular congestion within a gastric conduit,1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar but increasing the wall tension may potentiate the ischemic effects of gastric transposition for esophageal reconstruction.4Tang SJ Daram SR Wu R Bhaijee F Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarThird, air escape from the stomach to the esophagus after gastric insufflation may induce transient upper esophageal sphincter relaxation.5Lang IM Medda BK Shaker R Mechanism of UES relaxation initiated by gastric air distension.Am J Physiol Gastrointest Liver Physiol. 2014; 307: G452-G458Crossref PubMed Scopus (11) Google Scholar This effect is a consequence of receptor stimulation by the air pressure pulse in the esophagus, but not distention of the esophagus or an increase in esophageal pressure.5Lang IM Medda BK Shaker R Mechanism of UES relaxation initiated by gastric air distension.Am J Physiol Gastrointest Liver Physiol. 2014; 307: G452-G458Crossref PubMed Scopus (11) Google Scholar Upper esophageal sphincter relaxation may allow aspiration of gastric contents that may be associated with serious complications (ie, pulmonary aspiration and pneumonia).2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar These complications should be prevented and managed by nasogastric tube placement for intermittent air and fluid aspiration, if possible, as well as aggressive acid reduction (ie, via IV administration of proton pump inhibitors).4Tang SJ Daram SR Wu R Bhaijee F Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Thus, great care should be used not only to limit an increase in esophageal pressure, but, most importantly, to also reduce the risk of esophageal-gastric insufflation during NPPV after esophagectomy. To the EditorI read with great interest the article by Raman et al1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar in a recent issue of CHEST(February 2015) that evaluated the pressure tolerance of esophagectomy anastomosis ex vivo and in vivo in a pig model in comparison with esophageal pressure during noninvasive positive-pressure ventilation (NPPV). The authors showed that anastomosis can tolerate higher pressures than those transmitted to the esophagus during NPPV, thus demonstrating the safety of NPPV after esophagectomy.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Despite these data, however, in the clinical setting caution is necessary for several reasons when using pressures > 20 cm H2O during NPPV after esophagectomy.First, the authors found significant variability in pressure tolerance using ex vivo and in vivo models.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In their study, the lowest pressure tolerated by ex vivo anastomoses before leakage was 21 cm H2O.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google ScholarSecond, the risk of gastric insufflation during NPPV increases with pressure > 20 cm H2O.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Even if a pressure of ≤ 15 cm H2O is considered safe, a pressure of 15 to 20 cm H2O is also acceptable for preventing gastric insufflation during NPPV.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar During NPPV, the ventilation volume is distributed between the lungs and stomach, depending on the respiratory system resistance and the esophageal sphincter pressure.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar The resting upper esophageal sphincter pressure is lower in elderly individuals compared with young people (24 ± 9 mm Hg vs 42 ± 14 mm Hg,P < .001).3Amaris M Dua KS Naini SR Samuel E Shaker R Characterization of the upper esophageal sphincter response during cough.Chest. 2012; 142: 1229-1236Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Furthermore, the protective function of the lower esophageal sphincter is generally lost after esophagectomy.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In clinical esophageal surgery, postoperative gastric distention not only may cause decreased venous outflow and vascular congestion within a gastric conduit,1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar but increasing the wall tension may potentiate the ischemic effects of gastric transposition for esophageal reconstruction.4Tang SJ Daram SR Wu R Bhaijee F Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252Abstract Full Text Full Text PDF PubMed Scopus (35) Google ScholarThird, air escape from the stomach to the esophagus after gastric insufflation may induce transient upper esophageal sphincter relaxation.5Lang IM Medda BK Shaker R Mechanism of UES relaxation initiated by gastric air distension.Am J Physiol Gastrointest Liver Physiol. 2014; 307: G452-G458Crossref PubMed Scopus (11) Google Scholar This effect is a consequence of receptor stimulation by the air pressure pulse in the esophagus, but not distention of the esophagus or an increase in esophageal pressure.5Lang IM Medda BK Shaker R Mechanism of UES relaxation initiated by gastric air distension.Am J Physiol Gastrointest Liver Physiol. 2014; 307: G452-G458Crossref PubMed Scopus (11) Google Scholar Upper esophageal sphincter relaxation may allow aspiration of gastric contents that may be associated with serious complications (ie, pulmonary aspiration and pneumonia).2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar These complications should be prevented and managed by nasogastric tube placement for intermittent air and fluid aspiration, if possible, as well as aggressive acid reduction (ie, via IV administration of proton pump inhibitors).4Tang SJ Daram SR Wu R Bhaijee F Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Thus, great care should be used not only to limit an increase in esophageal pressure, but, most importantly, to also reduce the risk of esophageal-gastric insufflation during NPPV after esophagectomy. I read with great interest the article by Raman et al1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar in a recent issue of CHEST(February 2015) that evaluated the pressure tolerance of esophagectomy anastomosis ex vivo and in vivo in a pig model in comparison with esophageal pressure during noninvasive positive-pressure ventilation (NPPV). The authors showed that anastomosis can tolerate higher pressures than those transmitted to the esophagus during NPPV, thus demonstrating the safety of NPPV after esophagectomy.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Despite these data, however, in the clinical setting caution is necessary for several reasons when using pressures > 20 cm H2O during NPPV after esophagectomy. First, the authors found significant variability in pressure tolerance using ex vivo and in vivo models.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In their study, the lowest pressure tolerated by ex vivo anastomoses before leakage was 21 cm H2O.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Second, the risk of gastric insufflation during NPPV increases with pressure > 20 cm H2O.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Even if a pressure of ≤ 15 cm H2O is considered safe, a pressure of 15 to 20 cm H2O is also acceptable for preventing gastric insufflation during NPPV.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar During NPPV, the ventilation volume is distributed between the lungs and stomach, depending on the respiratory system resistance and the esophageal sphincter pressure.2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar The resting upper esophageal sphincter pressure is lower in elderly individuals compared with young people (24 ± 9 mm Hg vs 42 ± 14 mm Hg,P < .001).3Amaris M Dua KS Naini SR Samuel E Shaker R Characterization of the upper esophageal sphincter response during cough.Chest. 2012; 142: 1229-1236Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Furthermore, the protective function of the lower esophageal sphincter is generally lost after esophagectomy.1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar In clinical esophageal surgery, postoperative gastric distention not only may cause decreased venous outflow and vascular congestion within a gastric conduit,1Raman V MacGlaflin CE Erkmen CP Noninvasive positive pressure ventilation following esophagectomy: safety demonstrated in a pig model.Chest. 2015; 147: 356-361Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar but increasing the wall tension may potentiate the ischemic effects of gastric transposition for esophageal reconstruction.4Tang SJ Daram SR Wu R Bhaijee F Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Third, air escape from the stomach to the esophagus after gastric insufflation may induce transient upper esophageal sphincter relaxation.5Lang IM Medda BK Shaker R Mechanism of UES relaxation initiated by gastric air distension.Am J Physiol Gastrointest Liver Physiol. 2014; 307: G452-G458Crossref PubMed Scopus (11) Google Scholar This effect is a consequence of receptor stimulation by the air pressure pulse in the esophagus, but not distention of the esophagus or an increase in esophageal pressure.5Lang IM Medda BK Shaker R Mechanism of UES relaxation initiated by gastric air distension.Am J Physiol Gastrointest Liver Physiol. 2014; 307: G452-G458Crossref PubMed Scopus (11) Google Scholar Upper esophageal sphincter relaxation may allow aspiration of gastric contents that may be associated with serious complications (ie, pulmonary aspiration and pneumonia).2Carron M Freo U BaHammam AS et al.Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials.Br J Anaesth. 2013; 110: 896-914Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar These complications should be prevented and managed by nasogastric tube placement for intermittent air and fluid aspiration, if possible, as well as aggressive acid reduction (ie, via IV administration of proton pump inhibitors).4Tang SJ Daram SR Wu R Bhaijee F Pathogenesis, diagnosis, and management of gastric ischemia.Clin Gastroenterol Hepatol. 2014; 12: 246-252Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar Thus, great care should be used not only to limit an increase in esophageal pressure, but, most importantly, to also reduce the risk of esophageal-gastric insufflation during NPPV after esophagectomy." @default.
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