Life-threatening pneumothorax of the ventilated lung during thoracoscopic pleurectomy

Abstract

Life-threatening pneumothorax of the ventilated lung during thoracoscopic pleurectomyPurpose: To report the case of a patient who underwent right thoracoscopic pleurectomy with lung exclusion and developed contralateral (left) pneumothorax with resulting life-threatening alteration of the respiratory and cardiovascular functions.Clinical features: A 28-yr-old male was admitted to the intensive care unit for a well tolerated, second episode of spontaneous right pneumothorax and scheduled for right thoracoscopic pleurectomy. Anesthesia was induced and maintained with sufentanil and propofol. A double lumen endotracheal tube (ETr) was inserted, its correct positioning checked clinically and by fiberoptic bronchoscopy and the patient was placed in the left decubitus position. Approximately one hour into the procedure, during the second period of right pulmonary exclusion, SpO 2 values decreased within two minutes to 78%. End tidal capnography (EtCO2) values decreased to 6-8 mmHg within seconds and peak airway pressure increased to values between 50 and 60 cm H20. Severe cyanosis, sinus bradycardia and arterial hypotension developed. The surgical procedure was stopped, propofol administration discontinued, bipulmonary ventilation reinstituted and the patient placed in the supine position which restored hemodynamic and respiratory function. Inspection and auscultation were consistent with tension left pneumothorax which was evacuated.Conclusion: Pneumothorax of the ventilated lung during one lung ventilation for thoracoscopic procedures must be diagnosed quickly. Reinstitution of bipulmonary ventilation should probably be the first therapeutic attitude. p NEUMOTHORAX as a consequence of barotrauma is a relatively rare event during anesthesia accounting for approximately 3% of anesthetic complications. 1 Bilateral pneumothorax is even less frequent during anesthesia but, if not diagnosed rapidly, can be life-threatening. The recent development of thoracoscopy as a diagnostic and therapeutic procedure for thoracic surgery has added new challenges to anesthesiologists because the surgical field cannot be inspected easily.

Crisis management during anaesthesia: pneumothorax

“…6 The diagnosis of pneumothorax rests on thinking of the possibility whenever there are signs of circulatory or respiratory compromise or difficulty, especially in certain high risk situations (see box). The anaesthetist has an opportunity to diagnose a pneumothorax during inspection or examination of the chest during manual ventilation of the lungs (V1, SCAN, or CHECK levels of COVER) or at B of ABCD in the spontaneously breathing patient.…”

“…The reports do not reliably identify tension as a specific item and thus both tension and non-tension pneumothoraces are incorporated as one group. In the 17 positive reports these blood pressure and pulse changes were documented in eight; Any needle or instrumention, even days previously (4) In or near the neck or chest wall Down the trachea/bronchial tree External cardiac massage Fractured ribs, crush injury Blunt trauma/deceleration injury Problem with pleural drain already sited Airway overpressure, obstructed ETT Emphysema or bullous lung disease EMERGENCY MANAGEMENT Inform the surgeon Inspect the abdomen, or the diaphragm from below if visible Insert an IV cannula into the affected side (5) Turn off the nitrous oxide Insert a pleural drain at the same site (6) Continuously observe the bottle for bubbling and/or swinging Be vigilant for further deterioration in the patient, it may be due to:…”

“…Arrange a chest X-ray and look for: state of re-expansion of the lung position of the tip of the drain. See (6) and (7) below. Explain the nature of the problem to the patient before discharge from the recovery ward.…”

Contralateral tension pneumothorax during video‐assisted thorascoscopic surgery for lung cancer: a case report

“…Obstruction by sputum is usually observed with a current smoker, since the DLT has a narrow lumen and DLT misplacement can occur . Hypoxemia, hypotension, bradycardia, increased airway pressure, decreased end‐tidal CO 2 concentration and difficulty in ventilation of the dependent lung are significant clinical findings indicating a contralateral tension pneumothorax .…”

“…The exact incidence of contralateral pneumothorax during OLV is unknown. A PubMed search revealed 12 reported cases . The clinical features of these cases and our case are summarized in Table .…”