The use of high flow nasal oxygen in a patient with Duchenne muscular dystrophy with severe restrictive lung disease requiring dental extractions: a case report

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Presentation: A 22-year-old man with Duchenne muscular dystrophy (DMD) presented for removal of impacted third molars in his baseline health status. Comorbidities included decreased mobility, restrictive lung disease [forced vital capacity (FVC) 35% at baseline], adrenal insufficiency, and obstructive sleep apnea. Anesthetic challenge: General anesthetics are problematic in this population. The airway is typically compromised by macroglossia. Patients have reduced functional residual capacity, so time to desaturation after induction is reduced; in patients with FVC<50% there is high risk of postoperative pulmonary complications. Those with FVC<30% face further increased risk. The use of depolarizing neuromuscular blockade is contraindicated due to the risk of hyperkalemia. Residual nondepolarizing neuromuscular blockade could compromise postoperative pulmonary status further. Controversy remains regarding use of inhaled anesthetics, but they are generally avoided given the risk of rhabdomyolysis. In addition, DMD patients often have cardiomyopathy, further complicating management. The overall challenge was to avoid general anesthetics in this patient. How it was done: After a full discussion with the patient and family, we decided sedation with local anesthetic was the safest anesthetic plan. As a safeguard, inhaled anesthetics were removed, the machine was flushed, and filters were placed in the circuit; a Glidescope was available. We proceeded with moderate sedation with propofol and dexmedetomidine infusions. Given his reduced pulmonary function and need for oral access, the patient was placed on high-flow nasal cannula to provide supplemental oxygen and provide positive end-expiratory pressure. Opioids were kept to a minimum: 50 mcg fentanyl was given with local anesthetic injection. The anesthetic and dental teams talked the patient through his discomfort for much of the procedure. Music of the patient’s choosing was played. Overall the patient did well with a combination of sedation, local anesthesia, and coaching by the surgery and anesthesia teams. He was discharged same day without noted complications of anesthesia. Conclusion: Preparation for this apparently “simple” case in a complex patient was key to our success. By addressing the known pulmonary changes in DMD, we employed high-flow nasal cannula in a dental surgery—a new use for this device. By using all the tools available to us as anesthesiologists we were able to avoid an intubation and the possibility of a prolonged hospital stay for our patient.