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Chang AH, Chen H, Li L, Hu Y, Zhang R, Zhang X. Contralateral Tension Pneumothorax in One-Lung Ventilation: A Case Report and Systematic Review. Cureus 2024; 16:e61306. [PMID: 38813077 PMCID: PMC11135384 DOI: 10.7759/cureus.61306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 05/31/2024] Open
Abstract
Contralateral tension pneumothorax is a rare but fatal complication of one-lung ventilation. The life-saving decompression of pleural space was frequently delayed by the difficult confirmation of diagnosis because of general anesthesia that masks specific clinical presentations when the patient is alert. We reported a case of tension pneumothorax in a patient who underwent thoracic spine instrumentation. There were no contralateral tension pneumothorax cases on file from the search of the Anesthesia Quality Institute Closed Claims Database from 2001 to 2017. We systematically searched PubMed, Ovid MEDLINE, Embase, and Google Scholar. Over the past 30 years, there were 21 single case reports and two case series were retrieved. It was a consensus that difficult confirmation of the diagnosis of contralateral tension pneumothorax is the culprit of delayed life-saving intervention. Difficulty of oxygenation with increasing inspiratory pressure was usually the first sign suggesting contralateral pneumothorax; however, earlier presentations of cardiovascular system failure than respiratory failure have significantly increased the incidence of cardiac arrest and death. It is paramount to maintain a high suspicion of tension pneumothorax. The application of esophageal stethoscope, lung ultrasound, and simulator training may improve the chance of early diagnosis and patient outcome.
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Affiliation(s)
- Angie H Chang
- Anesthesiology, Geisinger Medical Center, Danville, USA
| | | | - Lei Li
- Anesthesiology, Geisinger Medical Center, Danville, USA
| | - Yirui Hu
- Epidemiology and Public Health, Henry Hood Center for Health Research, Geisinger Commonwealth School of Medicine, Danville, USA
| | - Ruoxi Zhang
- Basic Biomedical Sciences, Touro College of Osteopathic Medicine, Middletown, USA
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Woo JH, Cho S, Kim YJ, Kim DY, Choi Y, Lee JW. Depth of double-lumen endobronchial tube: a comparison between real practice and clinical recommendations using height-based formulae. Anesth Pain Med (Seoul) 2023; 18:37-45. [PMID: 36746900 PMCID: PMC9902630 DOI: 10.17085/apm.22214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/02/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The depth of double-lumen endobronchial tube (DLT) is reportedly known tobe directly proportional to height and several height-based recommendations have beensuggested. This retrospective study was designed to find out the difference between calculated depths using height-based formulae and realistic depths in clinical practice of DLTplacement by analyzing pooled data from patients intubated with left-sided DLT. METHODS The electronic medical records of adults, intubated with DLT from February 2018to December 2020, were reviewed. Data retrieved included age, sex, height, weight, andsize and depth of DLT. The finally documented DLT depth (depth final, DF) was comparedwith the calculated depths, and the relationship between height and DF was also evaluated.A questionnaire on endobronchial intubation method was sent to anesthesiologists. RESULTS A total of 503 out of 575 electronic records of consecutive patients were analyzed.Although the relationship between height and DF was shown to have significant correlation(Spearman's rho = 0.63, P < 0.001), DF was shown to be significantly greater than calculated depths (P < 0.001). Despite 57.1% of anesthesiologists have knowledge of clinical recommendations to anticipate size and depth of DLT, no one routinely utilizes those recommendations. CONCLUSIONS Anesthesiologists tend to place DLTs in a deeper position than expected whendepths are calculated using height-based recommendations. Although such discrepanciesmay not be clinically meaningful, efforts are needed to standardize the methods of endobronchial intubation to prevent potential complications associated with malposition.
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Affiliation(s)
- Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Sooyoung Cho
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Dong Yeon Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Yongju Choi
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ewha Womans University, Seoul, Korea,Corresponding author: Jong Wha Lee, M.D. Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea Tel: 82-2-2650-5560 Fax: 82-2-2655-2924 E-mail:
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Suvvari P, Kumar B, Singhal M, Singh H. Comparison between computerized tomography-guided bronchial width measurement versus conventional method for selection of adequate double lumen tube size. Ann Card Anaesth 2020; 22:358-364. [PMID: 31621669 PMCID: PMC6813693 DOI: 10.4103/aca.aca_117_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Selection of adequate size double lumen tube (DLT) is complicated by marked inter-individual variability in morphology and dimensions of tracheobronchial tree. Computerized tomography (CT)-guided left bronchus width measurement has been used to predict adequate size DLT in European and Singapore population; however, no such data exist for Indian population who are racially different. We compared the effect of DLT size selection based on CT-guided bronchial width measurement to the conventional method of DLT selection on the adequacy of both lungs isolation and on the safety margin of right-sided DLT. Methods: Fifty-five adults scheduled to undergo thoracotomy were enrolled in this prospective observational study. An appropriate size left- or right-sided DLT with outer diameter 0.5–1 mm smaller than the CT-measured bronchial width was selected for the isolation of lungs. Adequacy of separation was checked using fiberoptic bronchoscope. The safety margin of selected right-sided DLT size was calculated from CT-measured right upper lobe bronchus width and diameter of right upper lobe ventilation slot of the DLT. Results: Adequate separation of lungs was achieved in 92.7% of studied population, 90.9% in males, and 95.4% in females. Among these, 54.9% patients required different sized DLT as compared to conventional method. Overall safety of margin of right-sided DLTs was comparable between two methods of DLT selection (median [IQR] 4.8 (3.5–6.8) vs. 6.59 (3.5–7.8), P = 0.317). DLT size with adequate isolation of lung correlated with height, tracheal width (TW) on chest X-ray, and age of the patients. A formula to calculate DLT size based on these variable was derived. Conclusion: CT-measured bronchial width predicts the appropriate DLT size better than conventional method. In the absence of CT scan facility, patient height, age, and chest X-ray TW may be used to predict DLT size with reasonable accuracy.
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Affiliation(s)
- Praneeth Suvvari
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhupesh Kumar
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harkant Singh
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Lee SK, Seo KH, Kim YJ, Youn EJ, Lee JS, Park J, Moon HS. Cardiac arrest caused by contralateral tension pneumothorax during one-lung ventilation: - A case report. Anesth Pain Med (Seoul) 2020; 15:78-82. [PMID: 33329794 PMCID: PMC7713858 DOI: 10.17085/apm.2020.15.1.78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/30/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background Tension pneumothorax on the contralateral lung during one-lung ventilation (OLV) can be life-threatening if not rapidly diagnosed and managed. However, diagnosis is often delayed because the classic signs of tension pneumothorax are similar to clinical manifestations commonly observed during OLV. Case We report a case of contralateral tension pneumothorax in a patient undergoing right upper lobectomy during OLV. The patient suffered from sudden cardiac arrest and was assisted by extra-corporeal membrane oxygenation. Conclusions Contralateral pneumothorax during OLV is rare but can occur at any time. Therefore, anesthesiologists should consider this critical complication.
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Affiliation(s)
- Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Kwon Hui Seo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - You Jung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Eun Ji Youn
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Jun Suck Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Jieun Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
| | - Hyun Soo Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hallym University, Chuncheon, Korea
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Wang Y, Shi B, Li Y, Wang N. Spontaneous Bilateral Pneumothorax, Pneumomediastinum, and Subcutaneous Emphysema following Intracranial Aneurysm Clipping under General Anesthesia. Anesth Essays Res 2019; 13:184-187. [PMID: 31031503 PMCID: PMC6444971 DOI: 10.4103/aer.aer_167_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A 64-year-old male smoker who was previously healthy underwent intracranial aneurysm clipping after subarachnoid hemorrhage. Thoracic computerized tomography which was taken a day before the surgery revealed small bullae and low attenuation area in bilateral lower lobes. Soon after the completion of the surgery, the patient began to breathe, and then developed cough, 5 min later oxygen saturation decreased, and diminished breath sounds were detected in the left lung. Tube thoracostomy was performed and eventually resolved the complication. Bilateral pneumothorax, pneumomediastinum, and subcutaneous emphysema were confirmed by computerized tomography later. Early recognition and intervention of perioperative pneumothorax and pneumomediastinum can improve the patient's outcome.
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Affiliation(s)
- Yuanyuan Wang
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Bo Shi
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yanhui Li
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Na Wang
- Department of Anesthesiology, The First Hospital of Jilin University, Changchun, Jilin, China
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Hoechter DJ, Speck E, Siegl D, Laven H, Zwissler B, Kammerer T. Tension Pneumothorax During One-Lung Ventilation – An Underestimated Complication? J Cardiothorac Vasc Anesth 2018; 32:1398-1402. [DOI: 10.1053/j.jvca.2017.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Indexed: 01/28/2023]
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Demirkol D, Ataman Y, Gündoğdu G. Differential lung ventilation via tracheostomy using two endotracheal tubes in an infant: a case report. J Med Case Rep 2017; 11:255. [PMID: 28882178 PMCID: PMC5590188 DOI: 10.1186/s13256-017-1417-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 08/06/2017] [Indexed: 11/10/2022] Open
Abstract
Background This case report presents differential lung ventilation in an infant. The aim is to define an alternative technique for performing differential lung ventilation in children. To the best of our knowledge, this is the first report of this kind. Case presentation A 4.2-kg, 2.5-month-old Asian boy was referred to our facility with refractory hypoxemia and hypercarbia due to asymmetric lung disease with atelectasis of the left lung and hyperinflation of the right lung. He was unresponsive to conventional ventilator strategies; different ventilator settings were required. To perform differential lung ventilation, two separate single-lumen endotracheal tubes were inserted into the main bronchus of each lung by tracheotomy; the tracheal tubes were attached to discrete ventilators. The left lung was ventilated with a lung salvage strategy using high-frequency oscillatory ventilation, and the right lung was ventilated with a lung-protective strategy using pressure-regulated volume control mode. Differential lung ventilation was performed successfully with this technique without complications. Conclusions Differential lung ventilation may be a lifesaving procedure in select patients who have asymmetric lung disease. Inserting two single-lumen endotracheal tubes via tracheotomy for differential lung ventilation can be an effective and safe alternative method.
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Affiliation(s)
- Demet Demirkol
- Pediatric Intensive Care Unit, Koç University School of Medicine, Maltepe Mahallesi, Davutpasa Cad, 34010, Istanbul, Turkey.
| | - Yasemin Ataman
- Department of Pediatrics, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
| | - Gökhan Gündoğdu
- Pediatric Surgery Unit, Koç University School of Medicine, Istanbul, Turkey
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Abstract
Over the past few decades, major surgical procedures involving the thorax have become commonplace at most larger medical facilities. Advances in perioperative care have allowed surgeons to perform increasingly complex procedures. These procedures are being performed on more seriously ill patients who are at increased risk for significant complications. Recent advances should help the anesthesiologist avoid some of the pitfalls in managing these complex patients. Preoperative assessment aids in the identification of patients at highest risk for intraoperative and postoperative events. Particular attention is given to myasthenia gravis, as thymectomy is among the most common surgical procedures that are performed in these patients. Aggressive pain control techniques, including neuraxial opioids and patient-controlled analgesia, where appropriate, not only improve patient comfort but can improve postoperative pulmonary function. Advances in techniques for providing one-lung ventilation allow the anesthesiologist more options to individualize management for each clinical scenario. Careful fluid management may help to minimize the risk of postoperative pulmonary complications. A basic understanding of video-assisted thoracic surgery should help the anesthesiologist provide optimal surgical conditions and perioperative care. Recent advances demand a greater role for the anesthesiologist if the best outcomes are to be achieved in patients undergoing thoracic procedures.
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Arai H, Tajiri M, Ebuchi K, Ando K, Okudela K, Gamo M, Masuda M. Contralateral tension pneumothorax during video-assisted thorascoscopic surgery for lung cancer: a case report. CLINICAL RESPIRATORY JOURNAL 2016; 12:298-301. [DOI: 10.1111/crj.12470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/21/2016] [Accepted: 02/08/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Hiromasa Arai
- Department of General Thoracic Surgery; Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomiokahigashi; Kanazawa-ku Yokohama 236-8651 Japan
| | - Michihiko Tajiri
- Department of General Thoracic Surgery; Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomiokahigashi; Kanazawa-ku Yokohama 236-8651 Japan
| | - Keigo Ebuchi
- Department of Anesthesiology; Yokohoma City University Graduate School of Medicine, 3-9 Fukuura; Kanazawa-ku Yokohama 236-0004 Japan
| | - Kohei Ando
- Department of General Thoracic Surgery; Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomiokahigashi; Kanazawa-ku Yokohama 236-8651 Japan
| | - Koji Okudela
- Department of Pathology; Yokohoma City University Graduate School of Medicine, 3-9 Fukuura; Kanazawa-ku Yokohama 236-0004 Japan
| | - Masahiro Gamo
- Department of Anesthesiology; Kanagawa Cardiovascular and Respiratory Center, 6-16-1 Tomiokahigashi; Kanazawa-ku Yokohama 236-8651 Japan
| | - Munetaka Masuda
- Departoment of Surgery; Yokohoma City University Graduate School of Medicine, 3-9 Fukuura; Kanazawa-ku Yokohama 236-0004 Japan
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Teaching basic lung isolation skills on human anatomy simulator: attainment and retention of lung isolation skills. BMC Anesthesiol 2016; 16:7. [PMID: 26790624 PMCID: PMC4719687 DOI: 10.1186/s12871-015-0169-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 12/23/2015] [Indexed: 11/23/2022] Open
Abstract
Background Lung isolation skills, such as correct insertion of double lumen endobronchial tube and bronchial blocker, are essential in anesthesia training; however, how to teach novices these skills is underexplored. Our aims were to determine (1) if novices can be trained to a basic proficiency level of lung isolation skills, (2) whether video-didactic and simulation-based trainings are comparable in teaching lung isolation basic skills, and (3) whether novice learners’ lung isolation skills decay over time without practice. Methods First, five board certified anesthesiologist with experience of more than 100 successful lung isolations were tested on Human Airway Anatomy Simulator (HAAS) to establish Expert proficiency skill level. Thirty senior medical students, who were naive to bronchoscopy and lung isolation techniques (Novice) were randomized to video-didactic and simulation-based trainings to learn lung isolation skills. Before and after training, Novices’ performances were scored for correct placement using pass/fail scoring and a 5-point Global Rating Scale (GRS); and time of insertion was recorded. Fourteen novices were retested 2 months later to assess skill decay. Results Experts’ and novices’ double lumen endobronchial tube and bronchial blocker passing rates showed similar success rates after training (P >0.99). There were no differences between the video-didactic and simulation-based methods. Novices’ time of insertion decayed within 2 months without practice. Conclusion Novices could be trained to basic skill proficiency level of lung isolation. Video-didactic and simulation-based methods we utilized were found equally successful in training novices for lung isolation skills. Acquired skills partially decayed without practice. Electronic supplementary material The online version of this article (doi:10.1186/s12871-015-0169-7) contains supplementary material, which is available to authorized users.
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Abstract
Thoracic surgery encompasses a wide array of surgical techniques, most of which require lung isolation for surgical exposure in the pleural cavity; this, in turn, demands an extensive knowledge of respiratory mechanics and modalities of airway control. Likewise, effective treatment of an acute central airway obstruction calls for a systematic approach using clear communication between teams and a comprehensive knowledge of available therapeutic modalities by the surgeon.
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SKJEFLO GW, DYBWIK K. A new method of securing the airway for differential lung ventilation in intensive care. Acta Anaesthesiol Scand 2014; 58:463-7. [PMID: 24588330 DOI: 10.1111/aas.12285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2014] [Indexed: 12/12/2022]
Abstract
Differential lung ventilation to achieve optimised ventilation for each lung is a procedure rarely used in the intensive care unit, to treat select cases of severe unilateral lung disease in intensive care. However, existing techniques both for securing the airway and ventilating the lungs are challenging and have complications. We present the use of differential lung ventilation in the intensive care setting, securing the airway with a technique not previously described, using endotracheal tubes inserted through a tracheotomy and orally. In the course of 1 month, we treated three patients with unilateral atelectatic and consolidated lungs by differential lung ventilation. The left lung was ventilated through an endotracheal tube inserted into the left main stem bronchus through a tracheotomy. The right lung was ventilated through an endotracheal tube with the cuff positioned immediately under the vocal cord. In patient 1, the diseased lung remained consolidated after 24 h of differential lung ventilation. In the two other patients, the diseased lungs responded to differential lung ventilation by increased compliance and radiographic increased aeration. Differential ventilation of the lungs with this novel technique is feasible and may increase the likelihood of successful treatment of atelectatic lungs refractory to conventional ventilator strategies.
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Affiliation(s)
- G. W. SKJEFLO
- Department of Anesthesiology and Intensive Care; St. Olavs Hospital; Trondheim Norway
| | - K. DYBWIK
- Department of Anesthesiology; Nordland Hospital; Bodø Norway
- Faculty of Professional Studies; University of Nordland; Bodø Norway
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Siddik-Sayyid SM, Esso JJ, Aouad MT. Atrial Fibrillation Complicating Left Pneumothorax After Malpositioning of a Double-Lumen Tube. J Cardiothorac Vasc Anesth 2012; 26:e43-4. [DOI: 10.1053/j.jvca.2012.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Indexed: 11/11/2022]
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Affiliation(s)
- J B Brodsky
- Department of Anesthesia, H 3580, Stanford University Medical Center, Stanford, CA 94305, USA.
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15
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Lin YT, Zuo Z, Lo PH, Hseu SS, Chang WK, Chan KH, Yuan HB. Bilateral tension pneumothorax and tension pneumoperitoneum secondary to tracheal tear in a patient with relapsing polychondritis. J Chin Med Assoc 2009; 72:488-91. [PMID: 19762318 DOI: 10.1016/s1726-4901(09)70413-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Relapsing polychondritis (RP) is a rare disease that is characterized by recurrent inflammation and destruction of cartilage and connective tissues. RP can have significant airway pathology that may require procedures to maintain airway patency and thus may have serious implications for anesthesiologists. Anesthesiologists must be prepared to deal with the possible complications that may occur during airway manipulation in patients with RP. Here, we present a case of life-threatening bilateral tension pneumothorax and tension pneumoperitoneum that developed after a tracheal tear during Montgomery T-tube insertion in a patient with tracheal stenosis due to RP. Correct diagnosis was delayed due to a misdiagnosis of airway obstruction. As a result, we emphasize that bilateral tension pneumothorax should be considered during refractory cardiac arrest in patients with increased airway pressure. A high index of suspicion and adequate management are mandatory for patients to survive these life-threatening complications.
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Affiliation(s)
- Yu-Ting Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan, ROC
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Bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after thoracoscopic anterior fracture stabilization. Spine (Phila Pa 1976) 2009; 34:E371-5. [PMID: 19404168 DOI: 10.1097/brs.0b013e3181995c87] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report and clinical discussion. OBJECTIVE A rare case of air passage into multiple body compartments after thoracoscopic minimally invasive spine surgery is described. SUMMARY OF BACKGROUND DATA In recent years, there is growing interest in thoracoscopic minimally invasive spine surgery for the treatment of thoracic and lumbar spine fractures. Severe complications due to the operative procedure are rare. METHODS We present a case of a 73-year-old woman who developed bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after thoracoscopic anterior stabilization of a Th12 fracture. RESULTS The operative procedure was completed without any obvious intraoperative complications. Routine made postoperative radiograph of the chest revealed a pneumothorax on the right side, bilateral subphrenic free air, and bilateral supraclavicular air. Subsequently, a CT scan showed bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and a supraclavicular subcutaneous emphysema. Bronchoscopy, esophagogastroduodenoscopy, and laryngoscopy showed no hollow organ injury or any other pathologic changes. Intraabdominal free air and pneumothoraces could not be detected on thoracic radiographs after 2 days. The patient remained cardiopulmonary stable throughout the hospital course. CONCLUSION This report documents a rare case of air passage into multiple body compartments after thoracoscopic-assisted treatment of a spinal fracture, which has not yet been described previously. After exclusion of a tracheo-bronchial and hollow organ injury the process was self-limiting. To avoid this complication, special care should be taken to evacuate all intrathoracal air at the end of the endoscopic procedure.
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Kaneko Y, Nakazawa K, Yokoyama K, Ishikawa S, Uchida T, Takahashi M, Tsunoda A, Makita K. Subcutaneous emphysema and pneumomediastinum after translaryngeal intubation: tracheal perforation due to unsuccessful fiberoptic tracheal intubation. J Clin Anesth 2006; 18:135-7. [PMID: 16563333 DOI: 10.1016/j.jclinane.2005.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2004] [Accepted: 10/31/2005] [Indexed: 12/19/2022]
Abstract
A 77-year-old man was scheduled to undergo a cervical lymph node biopsy under general anesthesia. Although awake, nasotracheal fiberoptic intubation was initially planned because of an anticipated difficult airway, the attempt was unsuccessful. Orotracheal intubation was subsequently performed under direct laryngoscopy without difficulty. After initiating positive pressure mechanical ventilation, subcutaneous and mediastinal emphysema developed. The cause of this emphysema was considered to be tracheal perforation after an unsuccessful attempt at fiberoptic tracheal intubation.
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Affiliation(s)
- Yuko Kaneko
- Department of Anesthesiology and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo 1138519, Japan
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Anantham D, Jagadesan R, Tiew PEC. Clinical review: Independent lung ventilation in critical care. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:594-600. [PMID: 16356244 PMCID: PMC1414047 DOI: 10.1186/cc3827] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Independent lung ventilation (ILV) can be classified into anatomical and physiological lung separation. It requires either endobronchial blockade or double-lumen endotracheal tube intubation. Endobronchial blockade or selective double-lumen tube ventilation may necessitate temporary one lung ventilation. Anatomical lung separation isolates a diseased lung from contaminating the non-diseased lung. Physiological lung separation ventilates each lung as an independent unit. There are some clear indications for ILV as a primary intervention and as a rescue ventilator strategy in both anatomical and physiological lung separation. Potential pitfalls are related to establishing and maintaining lung isolation. Nevertheless, ILV can be used in the intensive care setting safely with a good understanding of its limitations and potential complications.
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Affiliation(s)
- Devanand Anantham
- Respiratory and Critical Care Medicine, Singapore General Hospital, 169608, Singapore.
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Abstract
The progress in lung separation technology has allowed anesthesiologists to become skillful in fiberoptic bronchoscopy techniques and to provide excellent lung exposure in thoracic surgery patients. Given the availability of two technologies--DLTs (right-sided and left-sided) and bronchial blocker technology (TCBU, Arndt, and Cohen--every case that requires lung collapse and OLV should receive the benefit of these devices. Because of its greater margin of safety, a left-sided DLT is the more common device used in lung separation. If any contraindication to placing a left-sided DLT exists, a right-sided DLT is an option for any specific situation (eg, left lung transplantation). For a patient who requires lung separation and presents with the dilemma of a difficult or abnormal airway, bronchial blockers offer more advantages. Regardless of the device used, the optimal position of these devices (DLTs and bronchial blockers) is achieved best with the use of fiberoptic bronchoscopy techniques first in supine and then in lateral decubitus position or whenever repositioning of the device is needed.
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Affiliation(s)
- Javier H Campos
- Department of Anesthesia, University of Iowa Health Care, 200 Hawkins Drive, Iowa City, IA 52242-1079, USA.
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21
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Brodsky JB. Fiberoptic bronchoscopy need not be a routine part of double-lumen tube placement. Curr Opin Anaesthesiol 2004; 17:7-11. [PMID: 17021523 DOI: 10.1097/00001503-200402000-00003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The debate continues as to whether a fiberoptic bronchoscope must be used to position a double-lumen tube. This review supports the argument that although bronchoscopy is extremely helpful, it is not always needed for the routine placement of left double-lumen tubes. RECENT FINDINGS Several recent clinical reports have demonstrated that an experienced anesthesiologist can safely and consistently position double-lumen tubes without bronchoscopic assistance. In order to do so several important factors must be considered. These include the appropriate choice of tube (left or right), size of tube, and endpoint for the depth of insertion. SUMMARY Although bronchoscopy is useful, no double-lumen tube positioning method is fail-safe. The choice of which approach to use, 'blind' versus fiberoptic bronchoscope-assisted, is influenced by many factors. Operator experience with any method increases the likelihood of success. A fiberoptic bronchoscope is not always needed for left double-lumen tube placement.
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Affiliation(s)
- Jay B Brodsky
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California 94305, USA.
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22
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Abstract
A variety of different endotracheal tubes are available for distinct purposes, though the majority of patients will be well served with the standard single-lumen endotracheal tube. Specialized endotracheal tubes have been developed to aid in specific situations and novel tubes continue to be evaluated as clinicians strive for improved outcomes in various clinical conditions. Ultimately, the choice of an endotracheal tube depends on the purpose it is intended to serve.
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Affiliation(s)
- Anthony W Gray
- Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA.
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23
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Affiliation(s)
- Jay B Brodsky
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA 94305, USA.
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24
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Abstract
A 76-year-old woman underwent double-lumen endotracheal tube intubation for right upper lobectomy. During one-lung ventilation, she developed tension pneumothorax on her dependent lung and suffered cardiac arrest. The presenting signs of tension pneumothorax--hypoxemia, hypotension, and increased airway pressure--are relatively common during this procedure, leading to a delay in diagnosis and effective treatment. When all three signs occur together during one-lung ventilation, cardiovascular collapse can result and serious consideration must be given to the diagnosis of tension pneumothorax in the dependent lung.
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Affiliation(s)
- Weili Weng
- Department of Anesthesiology, Winthrop University Hospital, Mineola, NY, USA.
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25
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26
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Malik S, Shapiro WA, Jablons D, Katz JA. Contralateral tension pneumothorax during one-lung ventilation for lobectomy: diagnosis aided by fiberoptic bronchoscopy. Anesth Analg 2002; 95:570-2, table of contents. [PMID: 12198039 DOI: 10.1097/00000539-200209000-00014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
IMPLICATIONS Tension pneumothorax during one-lung ventilation can be a life threatening emergency. Clinical diagnosis may be confusing in the operative setting. We present a case in which fiberoptic bronchoscopy excluded tube malpositioning and lead us to the diagnosis of a tension pneumothorax.
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Affiliation(s)
- Sundeep Malik
- Department of Anesthesia, University of California-San Francisco, 521 Parnassus Avenue, San Francisco, CA 94143-0648, USA
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27
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Malik S, Shapiro WA, Jablons D, Katz JA. Contralateral Tension Pneumothorax During One-Lung Ventilation for Lobectomy: Diagnosis Aided by Fiberoptic Bronchoscopy. Anesth Analg 2002. [DOI: 10.1213/00000539-200209000-00014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Gesundheit B, Preminger A, Harito B, Babyn P, Maayan C, Mei-Zahav M. Pneumomediastinum and subcutaneous emphysema in an 18-month-old child. J Pediatr 2002; 141:116-20. [PMID: 12091861 DOI: 10.1067/mpd.2002.123668] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Benjamin Gesundheit
- Department of Pediatrics, Hadassah Ein Karem and Mount Scopus, Jerusalem, Israel
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29
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Sucato DJ, Girgis M. Bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema following intubation with a double-lumen endotracheal tube for thoracoscopic anterior spinal release and fusion in a patient with idiopathic scoliosis. JOURNAL OF SPINAL DISORDERS & TECHNIQUES 2002; 15:133-8. [PMID: 11927822 DOI: 10.1097/00024720-200204000-00007] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recently, thoracoscopic approaches to the spine have taken on greater clinical applications in the treatment of spinal deformity with generally good results. However, the steep learning curve must be ascended by the surgeon and may lead to complications early in one's experience. There also exists a learning curve for the anesthesiologist to become adept at obtaining single lung ventilation and managing this throughout the operative procedure. We report a case of an 11-year-old patient with severe scoliosis who developed air in both chest cavities, mediastinum, peritoneum, retroperitoneum, and subcutaneous tissue after intubation with a double-lumen endotracheal tube. The patient remained hemodynamically stable throughout this period, and bilateral chest tubes were placed. The patient remained on the ventilator for 24 hours and was extubated without sequelae. Complications from a thoracoscopic approach to the spine for deformity are most often attributed to the learning curve of the surgeon; however, the entire operative team becomes exposed to the challenges of performing this procedure. This report documents a life-threatening complication of air throughout the chest, mediastinum, abdomen, and subcutaneous tissues in a patient with severe scoliosis.
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30
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Kurosaki K, Fushimi Y, Hara S, Kano S, Kuriiwa F, Nagai T, Endo T. Sudden death caused by tension pneumothorax after rupture of a thoracic aortic aneurysm. Case report. Am J Forensic Med Pathol 2001; 22:250-2. [PMID: 11563733 DOI: 10.1097/00000433-200109000-00009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A rare case of fatal tension pneumothorax is reported. An aged Japanese man with marked subcutaneous emphysema of the neck was found collapsed in a betting office. He was ascertained to have left tension pneumothorax, based on radiographic examinations carried out before his death. At autopsy, severe pneumomediastinum was observed, and the descending thoracic aorta with a ruptured dissecting aneurysm was closely adhered to the left lung pleura. The hemorrhage spread into the pulmonary parenchyma and finally spouted out from the surface of the lung apex. Because the blood loss itself was not fatal in quantity, it is concluded that the patient died of tension pneumothorax caused by a lung penetration from the rupture of an aortic aneurysm.
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Affiliation(s)
- K Kurosaki
- Department of Forensic Medicine, Tokyo Medical University, Sagamihara, Japan
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31
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Abstract
Left-sided double-lumen endotracheal tubes should be the tube of choice for most cases in which lung isolation is required. A right-sided double-lumen endotracheal tube can be used effectively when a contraindication to placing a left-sided double-lumen endotracheal tube exists. The method of choice to select left-sided double-lumen endotracheal tubes is based on chest radiograph or CT scan measurements of the trachea or bronchus. Based on clinical reports, Univents or WEB blockers may be a better choice for patients with difficult airways who require one-lung ventilation or for when a selective lobar blockade is needed. For all selective intubation, the method of choice for proper tube placement and bronchial blockade is fiberoptic bronchoscopy with the patient in a supine position at first or in a lateral decubitus position later, or if a malposition occurs.
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Affiliation(s)
- J H Campos
- Department of Anesthesia, College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.
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