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Pharyngeal reperforation following incentive spirometry - A case report Soeun

Despite its widespread use, complication of incentive spirometry has been rarely reported. We report a case of pharyngeal reperforation following incentive spirometry. A 75-year-old female, had a history of long-term steroid use, entered the intensive care unit for maintenance of mechanical ventilation following surgical repair of a pharyngeal perforation. After ventilator weaning, incentive spirometry was implemented on postoperative day 4. Immediately after incentive spirometry use, patient’s neck began to swell, and subcutaneous emphysema was palpated. Pharyngeal reperforation was suspected on neck computed tomography, and emergency surgery was performed. Surgery revealed a 3-cm long rupture from the hypopharynx to the esophagus. The causes were thought to be delayed wound healing due to long-term steroid use and a sudden increase in pharyngeal pressure due to incentive spirometry. In conclusion, particular attention should be paid when using incentive spirometry after head and neck surgery in patients with a history of long-term steroid use.

BALL ® , Leventon, Spain) was administered to promote lung expansion. The intensive care unit nurse monitored the pa-tient's appropriate use of incentive spirometry. The patient was instructed to perform slow, sustained inspiration for 5 seconds using the incentive spirometry device in the sitting position; the target inhalation volume was set to 1.7 L and the patient was instructed to use the incentive spirometry device 10 times per hour. Immediately after the application of incentive spirometry, the patient complained of neck pain and tachycardia. Subsequently, the patient's neck swelled, and her consciousness level dropped to the drowsy state.
Palpation was performed and a crackling sensation from the neck and the anterior chest wall to both upper arms was confirmed. At the time, the patient's vital signs were as follows: heart rate, 130-175 beats/min; systolic blood pressure,

DISCUSSION
The use of incentive spirometry is considered primarily to reduce postoperative pulmonary complications, for the patients who are high-risk or who are scheduled for high-risk surgery, the patients who are predicted to have difficulties with postoperative pain control, or the patients undergoing thoracoabdominal surgery [1,3]. In addition, incentive spirometry is employed for respiratory muscle training in patients with respiratory muscle weakness due to neuromuscular disease or spinal cord injury [1,2].
Both major head and neck surgery and long-term mechanical ventilation are risk factors for pulmonary complications, and previous studies have been reported the cases when incentive spirometry was applied to patients with such conditions. The incidence of postoperative pulmonary atelectasis Despite the widespread use, the efficacy of applying incentive spirometry after surgery remains controversial [8]. In this regard, Cassidy et al. [9] have suggested the I COUGH program, a multidisciplinary patient care program, as a novel method to reduce postoperative pulmonary complications.
The I COUGH program consists of the following components: incentive spirometry, coughing and deep breathing, oral care, understanding (patient and family education), getting out of bed frequently (at least 3 times daily), and head-of-bed elevation. The authors reported that, owing to the application of the I COUGH program, the incidence of pneumonia and unplanned re-intubation was reduced after surgery. Therefore, rather than being applied alone, incentive spirometry should be used as part of the multidisciplinary program. In our case, the patient also received the multidisciplinary patient care program after ventilator weaning. The patient had application of incentive spirometer, oral care, understanding, and head-of-bed elevation; yet, due to general weakness resulting from the long-term bed ridden state, the patient was unable to get out of bed frequently.
Pharyngeal perforation is usually caused by foreign body ingestion or iatrogenic causes such as endoscopic procedures; therefore, cases of spontaneous pharyngeal perforation by other miscellaneous causes are extremely rare [10][11][12].
Pharyngeal perforation occurs when the internal pressure of the pharynx suddenly and excessively increases, thereby leading to a rupture of the weak part of the pharyngeal wall by the pressure [10,11]. In the present report, the pharyngeal perforation is also thought to be caused by the above mentioned two factors, i.e. weakening of the pharyngeal wall and the subsequent development of the pharyngeal pressure beyond the durability of the pharyngeal wall. As to the first factor, the patient's medication history, which included the long-term use of a steroid, may have contributed to the delaying wound healing and weakening of the pharyngeal wall.
Specifically, corticosteroids are known to affect all three phases of wound healing-inflammatory, proliferative, and remodeling-which results in a reduced wound tensile strength and slow wound healing [13]. Previous research has reported that the use of chronic corticosteroids for a period exceeding 30 days before surgery causes a 2-3-fold increase in the risk of wound dehiscence, as well as a 2-5-fold higher rate of wound complications [13,14]. In a similar case, Gorosh et al. [15] reported a spontaneous tracheal wall rupture after cough in a giant cell arteritis patient who had used steroids for 8 years.
Another cause of the tracheal rupture, as suggested by the authors, was connective tissue fragility due to the long-term use of steroids. Second, an increase of pharyngeal pressure was thought to be due to the use of incentive spirometry. Incentive spirometry has been devised to mimic natural sigh or yawning [1]. Therefore, when incentive spirometry is applied, Similarly, Kim et al. [10] reported that, in the context of acute pharyngitis, even shouting can induce spontaneous pharyngeal perforation.
Before extubation, no abnormal findings in the postoperative neck CT before the ventilator weaning were observed.