A case requiring re-thoracotomy due to a significant reduction of tidal volume after commencement of chest tube drainage under pressure control ventilation following lower lobectomy

Abstract

Background The use of pressure-controlled ventilation (PCV) during one lung ventilation (OLV) has been popular to avoid high airway pressure. We experienced a case of a significant reduction of tidal volume (TV) after commencement of chest tube drainage under PCV following lower lobectomy, which required re-thoracotomy to evaluate the degree of air leak. Case presentation A 70-year-old man was scheduled for a lower lobectomy. OLV was managed by PCV. The driving pressure was set at 15–20 cmH2O with 4 cmH2O of positive end-expiratory pressure (PEEP). A chest drainage tube was placed after completion of lobectomy. To switch OLV to two lung ventilation (TLV), PCV settings were changed to the driving pressure at 10 cmH2O with 4 cmH2O of PEEP, which generated 450 ml of TV. Immediately after applying drainage (−10 cmH2O), TV decreased down to 250 ml. To maintain 450 ml of TV, PCV was switched to volume-controlled ventilation with 450 ml of TV, which raised the plateau pressure close to 24 cmH2O. Re-thoracotomy was done; however, significant findings were not detected. Conclusions We experienced a case of a significant reduction of TV immediately after chest tube drainage following lower lobectomy. Probably, negative intrapleural pressure increased the residual volume, which might have significantly affected the limited lung volume after lobectomy, resulting in decreasing TV during PCV.

The effects of chest drainage on pressure-controlled ventilation

“…Consequently, TVs may decrease after the commencement of chest drainage in such a situation. We have experience in managing a case of significant TV reduction after commencement of chest tube drainage under PCV following left lower lobectomy [ 6 ]. It was suspected that such a phenomenon occurred because continuous negative intrapleural pressure by chest drainage caused overextension of the lung, which increased elastance.…”

“…It was suspected that such a phenomenon occurred because continuous negative intrapleural pressure by chest drainage caused overextension of the lung, which increased elastance. Table 1 shows ventilating parameters in this case report [ 6 ]. In this case, TV decreased by 10 cmH 2 O of chest drainage even with the same driving pressure and PEEP because both P-TPP and EE-TPP were changed by the commencement of chest drainage.…”