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LETTER TO EDITOR
Year : 2015  |  Volume : 59  |  Issue : 4  |  Page : 257-258  

Bilateral asymptomatic pneumothorax in early post-operative period


1 Staff Anesthestist, Curie Institute, 25, rue d'Ulm 75005 Paris, France
2 Department of Anesthesia and Intensive Care, Paris Descartes University, Faculty of Medicine, Assistance Publique-Hôpitaux de Paris, Cochin University Hospital, EA 3623, 27 rue du Faubourg Saint Jacques 75679 Paris Cedex 14, France
3 Chairman, Department of Anesthesia and Critical Care, Curie Institute, 25, rue d'Ulm 75005 Paris, France

Date of Web Publication13-Apr-2015

Correspondence Address:
Dr. Abdelmalek Ghimouz
Staff Anesthetist, Curie Institute, 25 Rue d'Ulm, 75005 Paris
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.155010

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How to cite this article:
Ghimouz A, Lentschener C, Bonnet L, Goater P. Bilateral asymptomatic pneumothorax in early post-operative period. Indian J Anaesth 2015;59:257-8

How to cite this URL:
Ghimouz A, Lentschener C, Bonnet L, Goater P. Bilateral asymptomatic pneumothorax in early post-operative period. Indian J Anaesth [serial online] 2015 [cited 2021 Jul 29];59:257-8. Available from: https://www.ijaweb.org/text.asp?2015/59/4/257/155010

Sir,

Bilateral asymptomatic pneumothorax in the early post-operative period remains a possible and often challenging anaesthetic concern. We believe that recalling such complication is pedagogical. [1]

A 58-year-old, 176-cm, 62-kg, American Society of Anaesthesiologists physical status I man underwent conservative mandibulectomy. Pre-operative evaluation showed chronic obstructive pulmonary disease related to active smoking of 63-packet years of cigarettes. Tomodensitometry assessment had shown bullous emphysema with numerous blebs at the apices. After establishing routine monitoring, general anaesthesia was induced using propofol, remifentanil and cisatracurium. Nasotracheal intubation was easily performed. Anaesthesia was maintained using desflurane (3-4%) in N 2 O-O 2 mixture (50-50), sufentanil and cisatracurium. Mechanical ventilation (MV) was performed using a tidal volume of 7 ml/kg, respiratory rate 12/min, I: E ratio 1:2, peak inspiratory pressure (PIP) of 12-14 cm H 2 O, and expired CO 2 (PETCO 2 ) of 30-35 mm Hg. Surgery was performed in the supine position. At the end of the procedure, tracheotomy was performed, and a nasogastric tube was inserted for post-operative enteral feeding. In the post-anaesthesia care unit, the patient was spontaneously ventilating, conscious, calm and pain-free. Transcutaneous oxygen saturation was 98% with O 2 4 L/min, arterial blood pressure was 140/70 mm Hg, and heart rate 75 beats/min. Bilateral pneumothorax was diagnosed on chest X-ray, performed to confirm adequate nasogastric tube positioning [Figure 1]. Two chest tubes were inserted. Tracheo-bronchial endoscopy excluded a tracheal injury. The drains were removed 4 days later without further complications.
Figure 1: Chest X-ray showing bilateral pneumothorax

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Many risk factors for intraoperative pneumothoraces were identified. During MV, pneumothorax can develop as a result of increasing of PIP caused by bronchial spasm. [1] Pneumothoraces have been reported as a complication of high-frequency jet ventilation. [2] Tracheal injury during mediastinal or neck surgery has been associated with pneumothorax. [3] Carbon dioxide pneumothoraces have been reported during laparoscopic surgery. [4] N 2 O has been known for a long time to diffuse into body cavities increasing the volume of pneumothorax. [5] In patients with bullous emphysema, N 2 O may increase the volume of bullae increasing the risk of rupture. In patients with bullous emphysema, MV may increase intrinsic positive end-expiratory pressure through gas trapping, resulting in bullous expansion and rupture. Coughing may be a precipitant factor of bullous rupture during MV or when the patient recovers consciousness. [2] Barlow et al., investigated 100 patients undergoing tracheotomy and reported a 2% incidence of pneumothoraces, but did not advocate routine chest X-ray following this procedure. [6] Pneumothorax is often diagnosed in a patient with subcutaneous or mediastinal emphysema, oxygen desaturation, circulatory disturbance, or MV impairment with increase of peak pressure. [1],[3],[4] However, it is likely to go unnoticed post-operatively in a sedated, pain-free patient receiving supplemental oxygen, as in this case. Several risk factors were found in the reported patient including, heavy smoking, bullous emphysema, neck surgery, tracheotomy, MV and using of N 2 O. Indeed, N 2 O must be avoided in the presence of bullous emphysema. Diagnosis was made on chest X-ray requested for another purpose. Whether chest X-ray must be ordered as a routine during post-operative care in a patient with known risk factors needs to be discussed and agreed to at a local level.

 
   References Top

1.
Lee JY, Kim JU, An EH, Song E, Lee YM. Bilateral tension pneumothorax caused by an abrupt increase in airway pressure during cervical spine surgery in the prone position-A case report. Korean J Anesthesiol 2011;60:373-6.  Back to cited text no. 1
    
2.
Bellemain A, Ghimouz A, Goater P, Lentschener C, Esteve M. Bilateral tension pneumothorax after retrieval of transtracheal jet ventilation catheter. Ann Fr Anesth Reanim 2006;25:401-3.  Back to cited text no. 2
    
3.
Stupnik T, Steblaj S, Sok M. Major tracheal tear and bilateral tension pneumothorax complicating percutaneous tracheostomy. Arch Otolaryngol Head Neck Surg 2009;135:821-3.  Back to cited text no. 3
    
4.
Raveendran R, Prabu HN, Ninan S, Darmalingam S. Fast-track management of pneumothorax in laparoscopic surgery. Indian J Anaesth 2011;55:91-2.  Back to cited text no. 4
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5.
Kaur S, Cortiella J, Vacanti CA. Diffusion of nitrous oxide into the pleural cavity. Br J Anaesth 2001;87:894-6.  Back to cited text no. 5
    
6.
Barlow DW, Weymuller EA Jr, Wood DE. Tracheotomy and the role of postoperative chest radiography in adult patients. Ann Otol Rhinol Laryngol 1994;103:665-8.  Back to cited text no. 6
    


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