Abstract
We performed anesthetic management for a 90-year-old patient with severe chronic obstructive pulmonary disease（COPD）. At initial evaluation, the results of lung function tests were as follows：forced expiratory volume in 1.0 s（FEV1.0）, 1.09 L；FEV1.0/forced vital capacity, 33.6％. After preoperative pulmonary management with an anticholinergic drug, FEV1.0 increased by nearly 30％ compared to initial evaluation. General anesthesia was induced with propofol（50 mg）and rocuronium（40 mg）. Anesthesia was maintained with air-oxygen-sevoflurane and remifentanil. Although PaCO2 levels were high（55-58 mmHg）, we followed the theory of permissive hypercapnia, while maintaining low airway pressure and adequate expiratory time. We aimed to minimize the risks of postoperative respiratory depression and delayed ambulation. Although no problems were encountered at emergence and he was able to drink clear water uneventfully until noon on postoperative day 1, he choked on water and vomited in the afternoon while taking his medications. He choked on water again at night while gargling. Aspiration pneumonia developed on postoperative day 2. Recovery was achieved after 1 week and he remained free of aspiration after recovering from pneumonia. We were able to successfully complete the intended surgery under general anesthesia. The main factor underlying the pathogenesis of the development of aspiration pneumonia seemed to be oral intake of water under conditions of dysphagia due to resection of a right tongue cancer. Background factors to this situation were thought to be aging and a comorbidity of COPD.
