Pneumothorax during Anesthesia

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Pneumothorax during Anesthesia

• M and M Conference
• August 9, 2000
• F. L. Scamman, MD, Moderator

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Case 1

• Fiftyish female for laparoscopic Nissen
  fundoplication
• Otherwise healthy
• Nominal induction and early anesthetic course
• Surgeons had trouble wrapping stomach around the
  esophagus

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Case 1 Scenario

• Surgery is about 2/3 completed
• ET CO2 started to increase
• Increasing minute ventilation did not help
• Peak pressure started to increase
• SPO2 started down
• What is the differential list?

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Case 1 Differential List

• Bronchospasm
• Misplaced ET tube
• Pulmonary edema/CHF
• Extravasation of CO2
• Pneumothorax
• What physical exam findings were present?

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Case 1 Physical Findings

• Crepitus over left chest extending cephalad to
  eyelids
• Decreased lift of left chest
• Hyper-resonant to percussion
• Decreased breath sounds on left side
• How do you make the diagnosis of pneumothorax?

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Case 1 Diagnosis

• CXR showed 75 pneumothorax on left
• Also showed gas surrounding pericardium
• Also showed gas in SQ tissues
• CO2 volume for case was 135 l. but there were
  leaks around sheaths
• Treatment of pneumothorax?

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Case 1 Pneumothorax Treatment

• Fix the cause
• Chest tube
• Needle aspiration
• Nothing
• How did we treat it?

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Case 1 What We Did

• Told surgeons to finish case pronto
• CXR on table as they finished
• Told surgeons not to put in a chest tube
• Needle aspiration 2nd ICS MCL
• Tested aspirate for CO2. How? Why?
• Repeat CXR in PACU showed pneumothorax resolved

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Case 1 Analysis

• How could we have minimized the effect of the
  pneumothorax?
• Why did I insist on no chest tube?
• Was our decision making appropriate?

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Case 2

• 80 y/o female, type II diabetes, 2 years S/P CABG
  with prolonged intubation
• Subglottic tracheal stenosis
• Scheduled for DL, tracheal dilatation (laser),
  possible tracheotomy

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Case 2 Conduct of Anesthesia

• Standard monitors, mask O2, fentanyl
• Propofol induction, easy mask isoflurane
• Paralysis, table turned
• DL by Oto, supraglottic jet ventilation with N2O
  and supplemental propofol
• Good view of stenosis, ablation went well

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Case 2 Emergence

• Back to mask O2
• Patient became responsive but inadequate minute
  ventilation
• Retractions, falling saturation
• Reanesthetized and intubated with 5.5 oral
  without leak
• Oto and us decide to trach patient

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Case 2 Trouble

• Access to trachea hampered by short neck
• Lumen exposed with large leak, saturation starts
  to fall
• 4.0 Shiley passed into trachea
• No capnogram, cannot ventilate
• Falling saturation
• What do we do next?

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Case 2 Continuing Trouble

• Repositioned Shiley
• No capnogram, cannot ventilate, falling sat
• Repositioned Shiley
• No capnogram, cannot ventilate, falling sat
• What do we do next?

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Case 2 Additional Trouble

• Removed Shiley, advanced 5.5
• Capnogram returned, could ventilate, sats
  improved to low 80s
• Poor compliance, sats still in the 80s
• Replaced Shiley
• No capnogram, cannot ventilate, falling sat
• What do we do now?

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Case 2 Deep Trouble

• Called for help because we were missing
  something, both me and Oto
• Additional help arrives
• Hard to ventilate, sats in 70s, hypotensive
• Oto threads fiberscope through Shiley and into
  trachea
• Shiley passed into trachea over fiberscope

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Case 2 Trouble A Bit Better

• Now have capnogram but very low sats and low
  compliance
• Right chest decreased breath sounds and
  hyperresonant to percussion
• CXR obtained, showing Rt pneumothorax
• Sats better, BP up and TCV called
• Chest tube placed with gush of air

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Case 2 Trouble Resolving

• Sats, BP, compliance all improve
• Pt taken to SICU
• Uneventful recovery with trach left in place

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Case 2 Analysis

• What caused the failure to fly after the initial
  laser resection?
• What caused the failure to ventilate via the
  Shiley?
• What caused the pneumothorax?
• Why did we not call for help sooner?

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References

• Pneumothorax during laparoscopic Nissen
  fundoplication. Canadian Journal of Anaesthesia
  41854, 1994
• Acute ventilatory complications during
  laparoscopic upper abdominal surgery. Canadian
  Journal of Anaesthesia 4377, 1996

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References (2)

• Tension pneumothorax complicating jet ventilation
  via a cook airway exchange catheter.
  Anesthesiology 91557, 1999