A 60-year-old male had the symptoms of dyspnea, orthopnea, swelling in hands and feet, and cyanosis in lips and tongue for two months. He was admitted to a health-center and diagnosed with SVCS due to substernal goiter. After 2 days, his condition deteriorated, and he was admitted to emergency department of our hospital. On physical examination, excessive edema and cyanosis in upper chest wall and head-neck area were found out. His neck was short and thick with restricted movements. As he had developed dyspnea and arrhythmia, he was transferred to surgical intensive care unit. According to medical records, he had unsatisfactory sleep quality, excessive daytime sleepiness, severe snoring, and sleep apnea since 2 months ago. His body mass index (BMI) was 39 kg/m2, indicating obesity. Thyroid function tests revealed euthyroidism. His chest X-ray showed bilateral upper mediastinal enlargement and deviation of trachea (). Thorax computerized tomography (CT) revealed the deviation of trachea without obstruction, and compression of superior vena cava by the right lobe of thyroid gland. Previous polysomnography findings were obtained. Apnea-hypopnea index (AHI) was calculated as 26.7 episodes/h and nocturnal oxygen desaturation was documented as 65%. OSAS was diagnosed with the aid of polysomnography.\nAn urgent endotracheal intubation and mechanical ventilation were planned because of severe respiratory acidosis and hypercapnia (pH: 7.192, PaCO2: 145 mmHg, PaO2: 60 mmHg with 8 L/min nasal oxygen supplement). Following preoxygenation with 100% O2 via face mask, light anesthesia was induced with propofol, and laryngoscopy was applied without muscle relaxant. Spontaneous respiration was preserved after the administration of propofol. In the laryngoscopic assessment, Cormack and Lehane grade was considered as 4. The laryngeal Mask Airway (LMA) was placed promptly after failed endotracheal intubation. Mechanical ventilation was initiated through LMA and tracheostomy was performed uneventfully. The patient with SVCS was given antiedemal (steroid and diuretic), empiric antibiotic, and bronchodilator treatment in intensive care unit. Hence, his upper extremity and face-neck edema were reduced evidently. The steroid treatment was stopped, when nosocomial pneumonia was diagnosed on the 12th day. After the treatment of pneumonia, steroid treatment was restarted. The ventilatory mode was changed from synchronized intermittent mandatory ventilation (SIMV) to continuous positive airway pressure (CPAP) when arterial blood gas analysis revealed acceptable values (pH: 7.494, PaCO2 37.1 mmHg, PaO2 64.9 mmHg, HCO3 27.9 using FiO2 0.35) on the 35th day of mechanical ventilation. CPAP ventilation was applied for one week. Follow up T connector with oxygen supply was put on the tracheostomy cannula. Weaning was performed successfully on the 45th day.\nTracheal compression resulting from the enlargement of thyroid gland extending to substernal archus was detected in control CT after weaning (). The case was referred to thoracic surgeon, and he decided to perform thyroidectomy. The patient lost weight rapidly and thyroid function test indicated hyperthyroidism, which was attributed to the radiopaque agent used for CT. As soon as the result of thyroid function test returned to normal range, total thyroidectomy was performed successfully through collar incision and median sternotomy in elective conditions. Histopathological examination revealed a benign multinodular goiter. He was recovered and discharged from the hospital on the 14th postoperative day.
A 57-year-old male hypertensive Caucasian patient on medical treatment for 1.5 months for non-organic-related AF was hospitalized in the ICU because of high-ventricular response AF (170 per minute). Biphasic CV with 100J was performed on the patient under medical treatment, and sinus rhythm was maintained. The patient had high-ventricular response AF (160 per minute) again after 2 days, biphasic CV with 200J was conducted again, and sinus rhythm was maintained. An apnea test (AT) was performed on the same night because frequent apneas were observed during sedation, and his body mass index (BMI) was 40.9kg/m2. The results were as follows: apnea-hypopnea index (AHI) of 71 per hour, desaturation period of 28 minutes, and minimum peripheral oxygen saturation (SpO2) of 68 %. The patient was discharged with nocturnal BiPAP—expiratory positive airway pressure of 8cm H2O and inspiratory positive airway pressure of 14cm H2O—and medical treatment. The patient was in sinus rhythm at the 1-month follow-up; thus, medication doses were decreased, AT was performed under BiPAP at the 6-month follow-up, and the results were as follows: AHI of 1 per hour, desaturation period of 1 minute, and minimum SpO2 of 87 %. The patient did not have AF within these 6 months. At the 12th month, the patient decided to undergo gastric bypass surgery. Up to the time of surgery, nocturnal BiPAP and medical treatment were continued. Within 6 months after the medical surgery, the patient lost 40kg and only medical treatment was continued. In the AT conducted in the 18th month (via spontaneous breathing), results in the range of AHI of 5 per hour, apnea index of 1 per hour, and minimum SpO2 of 93 % were observed; hence, bisoprolol fumarate was ended (Fig. ).