Intra-operative Pneumothorax - potential causes

Started by jafo1964, October 23, 2008, 01:41:39 PM

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jafo1964

Presenting a case report and hoping to arrive at some answers from your knowledgeable inputs.

35 year old lady posted for laprotomy for growth ascending colon.
No significant past history or co-morbid illness.
Effort Tolerance > 4 mets (can climb 3 floors without any dyspnoea)
No allergy / drug intake

examination was all normal including resp system
Cxr was normal
Breath holding test > 25 secs
Assessed as ASA 2 due to malignancy and increased risk of peri-op DVT and Type C surgery requirements

In OT got all standard things done
Patient received a thoracic epidural to site the catheter tip at T9 for post-op analgesia.
Patient then received a GA consisting of Fentanyl 2 mcg/kg + Lignocaine 1.5 mg/kg + Thiopentone 5 mg/kg + Vecuronium 0.1 mg/kg
Ventilated for 3 mins
Laryngoscopy showed a class 2 Cormack Lehane but the laryngeal aditus appeared narrow
7mm ETT tried could not be passed
6.5 attempted - still not passing
Patient larynx finally accepted a 6 mm ETT

Connected to machine and IPPV started.
Bag a little tight
Auscultation showed ? wheeze
All anti-bronchospasm interventions undertaken
Meanwhile patient starting to desaturate and there is decreased airentry on right side
Diagnosis of Pneumothorax suspected.
Needle thoracostomy reveals air in pleural space
ICD inserted and surgery proceeds without any further event.

I saw this case post-operatively in the ICu with the ETT insitu and working ICD
24 hours later lung not re-expanded.
We continue checking ICD and Nebulized brochodilators  for another day
48 hours later - lung still collpased

We did a FOB and found right bronchus blocked with secretions.
We did a thorough suction
12 hours later CXR showed good expansion
24 hours later repeated FOB inspection and suction.
successful extubation was acheived later.

UNANSWERED DOUBTS
1. How did a normal lung develop pneumothorax? Where did we go wrong? Remember CXR - no bullae and resp reserve excellent
2. Did the secretions and intraluminal obstruction contribute to the pneumothorax in any way
3. Any better way of dealing with this case.

yogenbhatt1

That is an unusual event that took place. Must have baffled the Anaesthesiologist in charge.
ONly likely cause will be, some tiny leak of on old bulla not seen on CXR, which opened up due to high pressures generated, specially when a No.6 tube is used and bag was tight and one bronchus blocked.
But please do let us know the finding after further investigations took place, and also the progress of the pt.
Regards

mooh2007

Hi friend
i aced acase like yours it is most propably a mechanical trauma induced by repeated attempts for intubation
my best regards

jafo1964

I also think it was volutrauma
They got the small ETT way too in to produce endobronchial intubation
The tight bag was mistaken for Bronchospasm
Vigorous ventilation then lead to production of the iatrogenic pneumothorax

The subsequent persistent collapsed lung was due to intraluminal bronchial obstruction by inspissated secretions which needed removal under FOB guidance

Thankfully the patient made a complete recovery

regs