|Year : 2015 | Volume
| Issue : 2 | Page : 126-129
Spontaneous pneumothorax in the immediate post-operative hour in a primigravida following emergency caesarean section under spinal anaesthesia
Basheer Ahmed Khan, P Muralinath Reddy, Abrar Mohammed Khan
Department of Anaesthesiology, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad, Telangana, India
|Date of Web Publication||13-Feb-2015|
Dr. Basheer Ahmed Khan
17-1-388/P/62 and 65, Poornodaya Colony, Saidabad, Hyderabad - 500 059, Telangana
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Khan BA, Reddy P M, Khan AM. Spontaneous pneumothorax in the immediate post-operative hour in a primigravida following emergency caesarean section under spinal anaesthesia. Indian J Anaesth 2015;59:126-9
|How to cite this URL:|
Khan BA, Reddy P M, Khan AM. Spontaneous pneumothorax in the immediate post-operative hour in a primigravida following emergency caesarean section under spinal anaesthesia. Indian J Anaesth [serial online] 2015 [cited 2020 Jun 6];59:126-9. Available from: http://www.ijaweb.org/text.asp?2015/59/2/126/151380
| Introduction|| |
Pneumothorax can be primary or secondary. Primary pneumothorax is caused by rupture of undiagnosed pleural blebs or bullae.  The incidence of primary spontaneous pneumothorax is higher in males than females. , This article highlights the fact that spontaneous pneumothorax should be considered a differential diagnosis while managing a patient with acute onset respiratory distress in the immediate post-operative period even when the surgery (in this case a lower segment caesarean section) is performed under spinal anaesthesia.
| Case Report|| |
A 27-year-old, American Society of Anesthesiologists physical status I, primigravida with cephalopelvic disproportion presented at term and was scheduled for an emergency LSCS for failure to progress during the second stage of labour. She had been pushing vigorously for the previous 2 h. Her history was unremarkable for any respiratory or systemic disease. She gave no history of fever or trauma during the pregnancy. The patient was a non-smoker, and there was no history of drug abuse. Her airway and physical examination were unremarkable. Her haematological and biochemical profiles were normal. A thorough pre-anaesthetic evaluation was performed, anaesthetic concerns discussed and the patient signed a formal consent form for spinal anaesthesia.
In the operating room, baseline monitoring (oxygen saturation [SpO 2 ], non-invasive blood pressure and electrocardiogram [ECG]) was started. Under full aseptic precautions, spinal block was given with 2.5 ml of 0.5% hyperbaric bupivacaine (12.5 mg) and 60 μg of buprenorphine (total volume 2.7 ml) using 25-gauge spinal needle. Anaesthetic level assessment was tested by pinprick and measured at the T8 dermatome level. Reassessment several minutes later indicated a block at T6 level. Intraoperatively the patient was responding to verbal commands, maintained stable haemodynamics and saturation. About 6 min after the skin incision a healthy male child weighing 3.2 kg was delivered with an APGAR score of 8 at 1 min and 9 at 5 min. The uterus was well contracted with continuous oxytocin drip. The remaining intra-operative course was uneventful with a urine output of 150 ml and blood loss of 300 ml (approximately). After the procedure the patient was transferred to the post-anaesthetic care unit (PACU). Thirty min later in the PACU, the patient suddenly complained of severe left-sided chest pain and shortness of breath. She was restless and confused. The SpO 2 dropped below 90% despite oxygen supplementation with a face mask at 8 L/min flow. The patient became cyanosed and slipped into drowsiness with apnoeic spells. Her vitals recorded at the time were pulse rate as 130/min, respiratory rate as 38/min and blood pressure as 100/60 mm Hg. The patient was immediately rushed back to the operating room, the trachea intubated and manually ventilated with 100% oxygen using the Bain's circuit. Spontaneous breathing returned within a minute, but stiffness of the reservoir bag ventilation indicating decreased compliance was observed. Tachypnoea persisted, and end-tidal carbon dioxide was in the range of 40-45 mm Hg. Both pupils were normal in size and reactive to light. Clinical examination revealed absence of breath sounds on the left-side with a hyper-resonant note on percussion. There were no audible murmurs on auscultation. ECG monitor showed tachycardia, decrease in QRS amplitude along with T-wave inversions.
Subsequently, a bedside chest radiograph was obtained which showed a large left-sided pneumothorax with near total collapse of the underlying lung [Figure 1]. A computed tomography (CT) scan was obtained to confirm the diagnosis [Figure 1]. This was immediately followed by insertion of intercostal drain on the left-side and central venous line in the right subclavian vein. A repeat chest radiograph demonstrated complete expansion of the left lung with intercostal drain in the 5 th intercostal space and central line in the right subclavian vein [Figure 2]. The overall condition of the patient improved, cyanosis disappeared, and vitals returned to normal. Once fully conscious, the patient was transferred to the respiratory intensive care unit on mechanical ventilation. The patient was extubated on the second post-operative day with complete re-expansion of the lung on the third post-operative day.
|Figure 1: Chest radiograph showing collapsed left lung & Computed tomography scan showing left-sided pneumothorax prior to tube thoracostomy|
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|Figure 2: Chest radiograph demonstrating complete expansion of the left lung following intercostal drain insertion in the 5th intercostal space. Note the central line in the right subclavian vein|
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| Discussion|| |
Subpleural blebs and bullae are found in up to 90% of cases of primary pneumothorax at thoracoscopy or thoracotomy. 
Three cases of spontaneous pneumothorax under general anaesthesia and one under spinal anaesthesia (in a multigravida on the 2 nd post-operative day) have been reported. ,, The authors reporting occurrence in the above mentioned case reports claim that the likely operating mechanism may have been the pre-existent apical bullae or blebs that may have ruptured. Furthermore, pneumothorax is known to occur during general anaesthesia either in the patient with pre-existing lung disease or as a result of barotrauma due to intermittent positive pressure ventilation. 
In our case, we believe that vigorous pushing for 2 h (Valsalva manoeuvre) during the second stage of labour as well as the screaming may have caused the rupture of pre-existing subpleural blebs, as an ongoing process which became significant in post-operative period. In essence, prolonged second stage of labour with repeated vigorous expulsive efforts should be avoided in a primigravida with cephalopelvic disproportion. The possibility of tension pneumothorax should be borne in mind. Along with haemodynamic compromise, chest radiograph will show ipsilateral hyper-expansion and contralateral mediastinal deviation. 
Although CT scan was obtained in our case to distinguish it from other life-threatening conditions such as a large bulla or underlying emphysema, spontaneous pneumothorax is a clinical diagnosis confirmed with a chest radiograph requiring emergent needle decompression. Therapy should never be delayed for CT confirmation. Portable ultrasonography is also a rapid imaging option. In experienced hands, ultrasonography can be quicker and more accurate than radiography for distinguishing free pleural effusion (a finding in pneumothorax) in time-sensitive evaluations. 
| Conclusion|| |
Although uncommon in spinal anaesthesia, pneumothorax should always be considered in the list of differential diagnosis when managing acute respiratory distress during caesarean section or in the immediate post-operative period. Prompt treatment with needle aspiration (for immediate relief of tension pneumothorax) or intercostal drain insertion may be lifesaving.
| References|| |
Abdala OA, Levy RR, Bibiloni RH, Viso HD, De Souza M, Satler VH. Advantages of video assisted thoracic surgery in the treatment of spontaneous pneumothorax. Medicina (B Aires) 2001;61:157-60.
Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000;342:868-74.
Noppen M, De Keukeleire T. Pneumothorax. Respiration 2008;76:121-7.
Donahue DM, Wright CD, Viale G, Mathisen DJ. Resection of pulmonary blebs and pleurodesis for spontaneous pneumothorax. Chest 1993;104:1767-9.
Harris EA. Tension pneumothorax in a parturient undergoing cesarean delivery. Anesth Analg 2000;90:1173-4.
Harten JM, Brown AG, Davidson IT. Post partum pneumothorax: Two case reports and discussion. Int J Obstet Anesth 2000;9:286-9.
Madan K, Singh N, Jain V, Aggarwal AN. Spontaneous pneumothorax following caesarean section under spinal anaesthesia. BMJ Case Rep 2013;2013.
Shah V, Butala B, Parikh B, Raval R. Bilateral pneumothorax as a complication of laparoscopy. Indian J Anaesth 2003;47:55-6.
Leigh-Smith S, Harris T. Tension pneumothorax - Time for a re-think? Emerg Med J 2005;22:8-16.
Zanobetti M, Poggioni C, Pini R. Can chest ultrasonography replace standard chest radiography for evaluation of acute dyspnea in the ED? Chest 2011;139:1140-7.
[Figure 1], [Figure 2]