Video-assisted thoracoscopic volume reduction surgery in patients with diffuse pulmonary emphysema: gas exchange and anesthesiological management

Contralateral Tension Pneumothorax in One-Lung Ventilation: A Case Report and Systematic Review

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.

Cardiac arrest caused by contralateral tension pneumothorax during one-lung ventilation: - A case report

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.

[Hemodynamic monitoring in one-lung ventilation]

One-lung ventilation causes adverse effects in pulmonary gas exchange and cardiocirculatory function. These adverse effects become particularly important for patients with underlying cardiopulmonary comorbidities. Alterations in pulmonary gas exchange have been investigated in several experimental and clinical trials. However, the hemodynamic consequences of one-lung ventilation are to a great extent unknown. Furthermore, no conclusive recommendations exist as to which kind of hemodynamic monitoring should be preferred in the situation of one-lung ventilation. Many issues regarding hemodynamic monitoring in one-lung ventilation remain unacknowledged. This article will review the current literature on hemodynamic monitoring in one-lung ventilation in order to derive recommendations for the application of hemodynamic monitoring in this specific peri-operative situation.

Video-assisted thoracoscopic surgery

Video-assisted thoracoscopic surgery is finding an ever-increasing role in the diagnosis and treatment of a wide range of thoracic disorders that previously required sternotomy or open thoracotomy. The potential advantages of video-assisted thoracoscopic surgery include less postoperative pain, fewer operative complications, shortened hospital stay and reduced costs. The following review examines the surgical and anesthetic considerations of video-assisted thoracoscopic surgery, with an emphasis on recently published articles.

Anaesthesia for lung volume reduction surgery

To date, only a few published studies have been concerned with the anaesthesiological aspects of lung volume reduction surgery. This review summarizes the different anaesthetic concepts and offers a general strategy to meet specific requirements. Limitation of peak inspiratory pressure, tolerance of hypercapnia and avoidance of hypoxia during one-lung ventilation, and the immediate postoperative tracheal extubation of these patients, are considered to be crucial. However, many aspects of the procedure and of anaesthesiological management remain to be elucidated.

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

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.