Zia Ali, Sarfraz Khan Janjua.
Difficult to wean off ventilatory support in Myasthenic patients undergoing Thymectomy.
Pak Armed Forces Med J Jan ;58(3):350-2.

Our patient, a 70 years old lady, presented with 02 months history of easy fatigability, dysphagia and diplopia. On clinical examination she had bilateral ptosis, diplopia and upper limb raising test (muscle fatigue test for 1 minute) was positive. Peak expiratory flow rate was 150 liter/minute and she had motor power of grade III in all the limbs with intact sensory system. Her X-ray chest showed widening of the madiastinum and CT scan chest -revealed a well defined triangular soft tissue in anterior madiastinum. Thymectomy was performed through sternal split incision under general anaesthesia with minimal use of muscle relaxants (atracurium besylate). Postoperatively she was given tablet azathioprine 50 mg OD, tablet prednisolone 15 mg 8 hourly and tablet pyridostigmine 60 mg 6 hourly. On second post operative day the patient became restless and tachypnoeic and was placed on ventilator. On 7th post operative day her tracheostomy was performed. She was assessed daily to wean off and was given repeated tria ls but she used to exhaust and mechanical ventilation had to be resumed. Her plasmapheresis was done in two phases but she did not show much improvement. After that intravenous immunoglobulins 400 mg/kg body weight daily were infused for three consecutive days along with intensive nursing care, nutritional support and chest physiotherapy. She was placed on adaptive support ventilation, gradually encouraging her own ventilatory efforts. On 23rd post operative day she was placed on spontaneous ventilatory mode with continuous pressure support which was gradually decreased. Ultimately she was weaned off successfully on 43 post operative day.

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