Communication between the two pleural cavities after major cardiothoracic surgery: relevance to percutaneous intervention

The Legend of the Buffalo Chest

Background

The “buffalo chest” is a condition in which a simultaneous bilateral pneumothorax occurs due to a communication of both pleural cavities caused by an iatrogenic or idiopathic fenestration of the mediastinum. This rare condition is known by many clinicians because of a particular anecdote which stated that Native Americans could kill a North American bison with a single arrow in the chest by creating a simultaneous bilateral pneumothorax, due to the animal’s peculiar anatomy in which there is one contiguous pleural space due to an incomplete mediastinum.

Research Question

What evidence is there for the existence of buffalo chest?

Study Design and Methods

The term “buffalo chest” and its anecdote were first mentioned in a ‘‘personal communication’’ by a veterinarian in the Annals of Surgery in 1984. A mixed method research was performed on buffalo chest and its etiology. A total of 47 cases of buffalo chest were identified in humans.

Results

This study found that all authors were referring to the article from 1984 or to each other. Evidence was found for interpleural communications in other mammal species, but no literature on the anatomy of the mediastinum of the bison was found. The main reason for this research was fact-checking the origin of the anecdote and search for evidence for the existence of buffalo chest. Autopsies were performed on eight bison, and four indeed were found to have had interpleural communications.

Interpretation

We hypothesize that humans can also have interpleural fenestrations, which can be diagnosed when a pneumothorax occurs.

Failure to meet extubation criteria in the setting of suspected buffalo chest physiology

We report the case of a patient who failed to meet tracheal extubation criteria due to low tidal volumes from suspected buffalo chest, which is a single pleural space physiology. This presentation followed the resection of a large pleural mass in a 59-year-old woman with a history of exercise-induced asthma, hypertension and tumour-related chronic respiratory failure. Creation of a pleuro-pleural communication during the resection of this large, unilateral pleural mass led to bilateral pneumothoraces and contributed to patients inability to generate negative inspiratory force leading to failure to meet extubation criteria. Buffalo chest may be more prevalent than suspected and should be a differential diagnosis for low tidal volumes with spontaneous ventilation following thoracic surgery. It can be differentiated from other causes of decreased tidal volume using clinical examination, ultrasound and radiography. Bilateral chest tube placement can be considered to expedite pneumothorax resolution and tracheal extubation.

Pneumothorax and asthma

This review is focused on the relationship between asthma, pneumothorax and pneumomediastinum while presenting a number of case reports that include these conditions. The association between pneumothorax and asthma is not widely known. While asthma includes a common disorder and is prevalent worldwide, its morbidity and mortality is high when is associated with pneumothorax. Furthermore, the delayed diagnosis of pneumothorax while focusing on asthma includes the higher risk of coincidental pneumothorax in asthmatic patients. In addition, pneumomediastinum is considered benign and self-limiting condition that responds to conservative therapy. Although it is rare, the concurrence of pneumomediastinum with pneumothorax may prove fatal during a serious asthma attack. In conclusion, the symptoms of chest pain, dyspnea or focal chest findings when presented in asthmatic patients, must always create suspicion of pneumothorax or pneumomediastinum to the physician.

Iatrogenic bilateral pneumothorax following unilateral transbronchial lung biopsy

Bilateral pneumothoraces are recognized complications of thoracic procedures in patients who have undergone heart or heart-lung transplantation. Bilateral simultaneous pneumothoraces developing following a unilateral transbronchial lung biopsy in the absence of previous thoracic surgery has not been reported previously.

New suction guide needle designed to reduce the incidence of biopsy-related pneumothorax: experimental evaluation in canine model

In an attempt to remove air that enters the pleural space during computed tomography (CT)-guided coaxial transthoracic needle biopsy, the authors fashioned an 18-gauge experimental suction guide needle and evaluated the incidence of pneumothorax with this needle in comparison to the incidence of pneumothorax with a standard 18-gauge guide needle in a canine model. This experiment had animal care and use committee approval. Ten dogs underwent a biopsy of each lung, for a total of 20 lung biopsies. Half of the biopsies were performed by using the experimental needle (five right lungs, five left lungs), and half were performed by using a standard guide needle. CT revealed pneumothorax during the procedure and was performed to reveal pneumothorax 1 and 3 hours after the procedure. A significant reduction (P < .016) in intraprocedural lung biopsy-associated pneumothorax was found when the experimental guide needle was used.

Bilateral pneumothoraces after unilateral transthoracic needle biopsy of a lung nodule

The occurrence of pneumothorax after an invasive transthoracic procedure is a well-known complication. Less well-recognized is the occurrence of bilateral pneumothoraces after a unilateral intervention with a potential for life-threatening consequences in patients who have undergone median sternotomies. We present a patient who had undergone a thymoma resection in the remote past and developed bilateral pneumothoraces after undergoing transthoracic needle biopsy of a right lung nodule.

Delayed Bilateral Pneumothorax after Subclavian Vein Catheterization

A delayed bilateral pneumothorax complicated unilateral left subclavian vein catheterization and required treatment with tube thoracostomy. This case is unique in the demonstration that bilateral pneumothorax can present in a delayed fashion, and that, as a result of a previously formed pleuropleural fistula, it can occur in patients with a history of noncardiac surgery involving median sternotomy. Historical data on delayed pneumothoraces and bilateral pneumothoraces are presented.

Bilateral pneumothorax after percutaneous transthoracic needle biopsy. Evidence for incomplete pleural fusion

Although the pleural cavities are anatomically separate in humans, we describe bilateral pneumothoraces that occurred after percutaneous needle biopsy of the lung. In some individuals, there may be communication between the pleural spaces; it is important for those performing interventional procedures to be aware of this uncommon anatomic variant.