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From the Department of Anesthesia and Surgical Intensive Care, Hôpital Brabois-Adultes, Vandoeuvre-les- Nancy, France.
Address correspondence to: Dr. Dan Longrois, Department of Anesthesia and Surgical Intensive Care, Hôpital Brabois-Adultes, 4, rue du Morvan, 54500 Vandoeuvre-les-Nancy, France. Phone: 33 3 83 15 41 66; Fax: 33 3 83 15 36 88; E-mail: d.longrois{at}chu-nancy.fr
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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 (ETT) 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, SpO2 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 H2O. 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.
PNEUMOTHORAX 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.
We report the case of a patient who, during right lung exclusion for a thoracoscopic procedure, developed hypoxemia, increased airway pressure, decreased end-tidal CO2 (EtCO2) concentrations, sinus bradycardia and arterial hypotension.
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After premedication with 100 mg hydroxyzine po, placement of the venous line and the usual monitoring, anesthesia was induced with sufentanil and propofol. Tracheal intubation was facilitated with rocuronium bromide. Anesthesia was maintained with propofol and sufentanil titrated to the hemodynamic reactions to noxious stimuli. After placement of a double lumen endotracheal tube (ETT) (Carlens, Size 39, Mallinckrodt®, les Ulis, France), mechanical ventilation was initiated with a tidal volume of 600 ml and a respiratory rate of 13 breaths•min–1. The inspired oxygen fraction was set to 1. Correct positioning of the double lumen ETT was verified clinically and by fiberoptic bronchoscopy. The patient was placed in the left decubitus position and correct positioning of the double lumen ETT tube checked again, both clinically and by fiberoptic bronchoscopy. Peak airway pressures value, as displayed by the anesthesia machine (Monnal A®, Taema®, Antony, France), were 25 cm H2O.
The right chest tube was withdrawn and the thoracoscopic procedure started. Exclusion of the right lung was uneventful and there was no increase in peak airway pressure. Oxygen saturation (Sp02) measured by pulse oxymetry (Oxycapno 1000®, Nellcor®, Jouy-en-Josas, France) decreased progressively from 100% to 90% after 30 min of right pulmonary exclusion. Bipulmonary ventilation was reinstituted for several minutes and SpO2 values increased to 98%. The right lung was again excluded and peak airway pressure values increased to 30 cm H20.
Approximately one hour into the procedure, SpO2 values decreased within two minutes to 78%. EtCO2 decreased to 6–8 mmHg within seconds and peak airway pressures between 50 and 60 cm H2O were observed while the patient was still on controlled ventilation. Manual ventilation was instituted and increased airway pressure was confirmed. The patient became severely cyanotic, heart rate decreased to 50 beats•min–1 (sinus bradycardia) and blood pressure could not be measured (Collin PressMate®, Baxter, Maurepas, France). Carotid artery pulse pressure was barely perceived. The surgical procedure was stopped, propofol administration discontinued and bipulmonary ventilation reinstituted. The correct position of the double lumen ETT was checked by fiberoptic bronchoscopy. The patient was placed in the supine position and right chest tube thoracostomy performed followed by closure of the surgical incision. SpO2 increased to 100%, heart rate and blood pressure values became normal and EtCO2 increased to 39 mmHg. Upon inspection, the patient presented a major distension of the left hemithorax and lung auscultation was consistent with the diagnosis of left pneumothorax. Left chest tube thoracostomy confirmed the left tension pneumothorax. The double lumen ETT was replaced with a single lumen ETT. Lung auscultation revealed bilateral symmetric breath sounds.
The surgical procedure was cancelled and the patient transferred to the ICU intubated and ventilated mechanically. His postoperative course was uneventful. The trachea was extubated two hours after his arrival to the ICU. The patient left the ICU on the following morning and the hospital on the 5th postoperative day without sequelae. Long-term follow-up of the patient could not be performed.
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The development of thoracoscopy has profoundly changed the therapeutic strategy for these patients.3–5 Treatment of recurrent pneumothorax is one of the main indications of thoracoscopy5 because it provides a complete view of the thoracic cavity, of the lung together with the visceral and parietal pleura2,6 and allows several surgical procedures such as mechanical or chemical pleurodesis.2 However, thoracoscopy requires the exclusion of the lung and one lung ventilation.
Hypoxemia occurring after institution of one lung ventilation is not uncommon and is the expected consequence of persistent perfusion of the excluded lung.7,8 The first episode of hypoxemia in this case report is consistent with this mechanism. In contrast, the second episode of hypoxemia occurred rapidly, coincided with increased peak airway pressure, decreased EtCO2 and impaired cardiovascular performance. Several clinical situations could have resulted in similar clinical signs:
Incorrect positioning of the double lumen could have explained several clinical signs but fiberoptic bronchoscopy eliminated this diagnosis.
Anesthesia machine malfunction could not explain the clinical signs since increased airway pressure persisted during manual ventilation.
Systemic gaseous embolism has been reported during mechanical ventilation in adults and could have explained most of the clinical signs (hypoxemia, decreased EtCO2, bradycardia and arterial hypotension) but not the increased peak airway pressure.
A hemorrhagic complication, difficult to diagnose because of the thoracoscopic procedure, could have mimicked the decreased EtCO2, the hemodynamic instability but not the increased airway pressure in the absence of major intraalveolar hemorrhage.
Tension pneumothorax of the ventilated lung could explain all the clinical signs observed.
The main causes of pneumothorax during anesthesia are regional blocks (40% of reported cases), airway instrumentation (19%), barotrauma (16%) and placement of central venous lines (7%).1,7 The most probable cause of pneumothorax in this case is barotrauma which occurred despite airway pressures below 40 cm H2O, as displayed by the anesthesia machine. Occurrence of a pneumothorax on the ventilated lung, and particularly of a tension pneumothorax, can be life-threatening if not rapidly diagnosed. Immediate reinstitution of double lung ventilation was life-saving for the patient and should probably represent the first therapeutic attitude.
It is difficult to incriminate the thoracoscopy technique per se as the cause of barotrauma although it cannot be formally excluded. Complications of thoracoscopy have been reported in a cohort of 1337 patients in which the authors reported one death (0.07%) and 56 non-lethal complications (4.26%). Several other large thoracoscopy series did not report pneumothorax of the ventilated lung during one lung ventilation as a complication of the thoracoscopic procedure.3,4,6,7,9–14 The thoracoscopic procedure, because of its lack of direct vision of the surgical field, certainly increases the diagnostic difficulties.
Anesthesiologists should be aware that a pneumothorax of the ventilated lung during lung exclusion can occur, as reported previously.15–17 Thoracoscopy, by obscuring the surgical field and the mediastinum can make the diagnosis of this life-threatening complication more difficult. Barotrauma, which is probably the most frequent cause of pneumothorax during anesthesia, could be prevented by the use of pressure-limited ventilation with permissive hypercapnia.
In conclusion, we present the case of a patient who developed a life-threatening pneumothorax of the ventilated lung during one-lung ventilation for therapeutic thoracoscopy of a recurrent pneumothorax. The clinical signs developed quickly and the diagnosis was obscured by the lack of access to the surgical field. Reinstitution of bipulmonary ventilation was probably life-saving in this case.
Accepted for publication January 15, 2001.
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2
Liu H-P, Chang C-H, Lin PJ, Hsieh MJ. Thoracoscopic loop ligation of parenchymal blebs and bullae: is it effective and safe? J Thorac Cardiovasc Surg 1997; 113: 50–4.
3 Freixinet J, Canalis E, Rivas JJ, et al. Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery. Eur Respir J 1997; 10: 409–11.[Abstract]
4
Mouroux J, Elkaim D, Padovani B, et al. Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases. J Thorac Cardiovasc Surg 1996; 112: 385–91.
5 Mouroux J, Maalouf J, Bernard JL, et al. Video-assisted thoracic surgery: indications and limitations (French). Ann Chir 1994; 48: 37–42.[Medline]
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Krasna MJ, Deshmukh S, McLaughlin JS. Complications of thoracoscopy. Ann Thorac Surg 1996; 61: 1066–9.
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9 DeCamp MM Jr, Jaklitsch MT, Mentzer SJ, Harpole DH Jr, Sugarbaker DJ. The safety and versatility of video-thoracoscopy: a prospective analysis of 895 consecutive cases. J Am Coll Surg 1995; 181: 113–20.[Medline]
10 Hazelrigg SR, Nunchuck SK, LoCicero J, and the Video Assisted Thoracic Surgery Study Group. Video assisted thoracic surgery study group data. Ann Thorac Surg 1993; 56: 1039–43.[Abstract]
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Jancovici R, Lang-Lazdunski L, Pons F, et al. Complications of video-assisted thoracic surgery: a five-year experience. Ann Thorac Surg 1996; 61: 533–7.
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13 Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and efficacy of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1995; 109: 1198–204.
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Yim APC, Liu H-P. Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia. Ann Thorac Surg 1996; 61: 538–41.
15 Stuhmeier K-D, Mainzer B, Lipfert P, Torsello G. Ipsilateral pneumothorax in one-lung respiration. A rare, recently diagnosed and atypical complication of a double lumen tube (German). Anaesthesist.1997; 46: 43–5.[Medline]
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Laishley RS, Aps C. Tension pneumothorax and pulse oximetry. Br J Anaesth 1991; 66: 250–2.
17 Gabbott DA, Carter JA. Contralateral tension pneumothorax during thoracotomy for lung resection. Anaesthesia 1990; 45: 229–31.[Medline]
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