Respiratory arrest requiring resuscitation as a rare presentation of obstructive sleep apnoea and hypothyroidism

A 79-year-old man, who had significant cardiovascular morbidities, presented with out-of-hospital respiratory arrest. He regained breathing after brief cardiopulmonary resuscitation by his paramedic son. After meticulous investigations, acute cardiovascular events and metabolic causes were ruled out while features of obstructive sleep apnoea were elicited. The findings on in-laboratory polysomnography were compatible with severe obstructive sleep apnoea, with unusually prolonged apnoea duration of up to 2.7 min which most likely accounts for the presentation as ‘respiratory arrest’. Thyroid function test for investigation of his weight gain confirmed hypothyroidism. His symptoms improved gradually after positive airway pressure therapy with bi-level support and thyroxine replacement. On further evaluation, his hypothyroidism is believed to be a complication of long-term amiodarone exposure. The case highlights that the combination of obstructive sleep apnoea and hypothyroidism can lead to catastrophic manifestation and the unusually long apnoea could be a feature prompting further workup for possible hypothyroidism.

Randomized Double-blind Comparison of Ketamine-Propofol, Fentanyl-Propofol and Propofol-Saline on Haemodynamics and Laryngeal Mask Airway Insertion Conditions

The aim of this prospective, double-blind, randomized, placebo-controlled clinical trial was to investigate whether the administration of ketamine before induction with propofol improves its associated haemodynamic profile and laryngeal mask airway (LMA) insertion conditions. Ninety adult patients were randomly allocated to receive either ketamine 0.5 mg.kg-1 (n=30), fentanyl 1 μg.kg-1 (n=30) or normal saline (n=30), before induction of anaesthesia with propofol 2.5 mg.kg-1. Insertion of the LMA was performed 60s after injection of propofol. Arterial blood pressure and heart rate were measured before induction (baseline), immediately after induction, immediately before LMA insertion, immediately after LMA insertion and every minute for three minutes after LMA insertion. Following LMA insertion, the following six subjective endpoints were graded by a blinded anaesthestist using ordinal scales graded 1 to 3: mouth opening, gagging, swallowing, movement, laryngospasm and ease of insertion. Systolic blood pressure was significantly higher following ketamine than either fentanyl (P=0.010) or saline (P=0.0001). The median (interquartile range) summed score describing the overall insertion conditions were similar in the ketamine [median 7.0, interquartile range (6.0–8.0)] and fentanyl groups [median 7.0, interquartile range (6.0–8.0)]. Both appeared significantly better than the saline group [median 8.0, interquartile range (6.75–9.25); P=0.024]. The incidence of prolonged apnoea (>120s) was higher in the fentanyl group [23.1% (7/30)] compared with the ketamine [6.3% (2/30)] and saline groups [3.3% (1/30)]. We conclude that the addition of ketamine 0.5 mg.kg–1 improves haemo-dynamics when compared to fentanyl 1 μg.kg–1, with less prolonged apnoea, and is associated with better LMA insertion conditions than placebo (saline).

Apnoea in Amphibians and Reptiles

The amphibian ancestor had two gas exchangers, one working in water and one in air. It also ventilated the aerial exchanger in an intermittent fashion. The functional repercussions of thie ancestry can be seen in all amphibians and reptiles. During periods of apnoea, which almost all amphibians and reptiles show in their breathing patterns, there are variable fluctuations in lung and arterial PO2 and PCO2. Arterial PCO2 and pH show only small fluctuations during apnoea induced by voluntary dives, and blood lactate does not build up. More considerable acidoses and lactate accumulations occur in forced dives which the animals can readily survive, even when the dives are prolonged. Anaerobic metabolism plays an important role in their capacity to survive prolonged apnoea. Amphibians ventilate their lungs with a buccal pump whose pattern of activity differs from species to species. Short periods of apnoea characterize the more terrestrial forms. Long dives punctuated by bursts of lung ventilation, or irregular bouts of breathing with no distinctive pattern occur in more aquatic forms. Similar differences in pattern can be seen in terrestrial and aquatic reptiles. The most striking characteristic of ventilation is its extreme variability, even in a single individual. Responses occur to decreasing oxygen tensions and increasing carbon dioxide tensions in inspired air, alveolar air, and arterial blood, the animals almost always increasing lung ventilation and decreasing the duration of apnoea. However, no simple relationship can be seen between the tensions of respiratory gases in lungs or arterial blood and the beginning or end of an apnoeic period. Periods of apnoea are accompanied by vasoconstriction in the lung vasculature. This has the effect of decreasing blood flow to the lung and increasing right to left shunt in the incompletely divided heart.