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BILATERAL PNEUMOTHORAX FOLLOWING TRACHEAL INTUBATION
Br. J. Anaesth. (1989), 62, 338-339
BILATERAL PNEUMOTHORAX FOLLOWING TRACHEAL INTUBATION C. BISWAS, N. JANA AND S. MAITRA
A 65-yr-old woman weighing 60 kg was admitted to RG Kar Medical College and Hospital, Calcutta, for elective cholecystectomy. Preoperative assessment showed that the patient was otherwise healthy. Heart rate was 80 beat min"1 and regular, arterial pressure 125/80 mm Hg and rate of ventilation 14 b.p.m. Examination of heart and lungs showed no abnormality and the patient's past medical history did not indicate any respiratory disease. Preoperative investigation revealed normal haematology and biochemical values and the electrocardiogram and chest x-ray did not show any abnormality. On the night before the operation, the patient was given diazepam 10 mg by mouth to allay anxiety. Premedication was with pethidine 50 mg and trimeprazine 25 mg i.m 1 h before operation. After pre-oxygenation for 5 min, anaesthesia was induced with thiopentone 3.5mgkg~1. Gallamine 2 mg kg"1 was given and tracheal intubation was performed under direct vision using a size 8 red rubber tracheal tube. Following intubation of the trachea, the lungs were ventilated manually with nitrous oxide 5 litre min"1 and oxygen 3 litre min"1 using a circle system. On auscultation of the lung fields, breath sounds were audible only at the apical regions. Approximately 2 min later, the patient developed cyanosis. Surgical emphysema began to develop on both sides of the neck, chest, abdomen and inguinal regions. Percussion of the chest revealed bilateral hyperresonance. The operation was cancelled. Neostigmine C.BISWAS,* D.A. (ENGL.); N.JANA, D.G.O.(CAL.)> D.A.(CAL.), M.D.(CAL.); S. MAITRA, D.A.(CAL.) M.S.(CAL.); Department of
Anaesthesia, R. G. Kar Medical College and Hospital, Calcutta, India. Accepted for Publication: August 3, 1988. Address for correspondence: 16/14 Beleghata Main Road, Calcutta 700010, India.
SUMMARY An elderly patient undergoing elective cholecystectomy. developed bilateral pneumothorax following intubation of the trachea and manual ventilation of the lungs. Diagnosis was confirmed by chest x-ray and drainage with wide bore cannufae. Drainage of the chest was necessary.
2.5 mg and atropine 1.2 mg were given i.v. to antagonize neuromuscular block and the lungs were ventilated with 100% oxygen. Shallow spontaneous ventilation was established quickly, but the patient remained cyanosed, even though she was breathing 100% oxygen. Cardiac arrest occurred 2 min later. Immediate external cardiac massage was applied and the patient was resuscitated successfully. Sodium bicarbonate 50 mmol litre"1 was given i.v. with hydrocortisone 200 mg. Facilities were not available for analysis of arterial blood, but chest x-ray was performed and showed bilateral collapse of the lungs with massive bilateral pneumothoraces (fig. 1). The diagnosis was confirmed by bilateral insertion of catheters into the pleural cavities. The catheters were connected to closed tube drainage systems and within minutes both lungs expanded and breath sounds were heard on auscultation. A repeated chest x-ray showed expansion of both lungs. The patient's condition improved dramatically and she was able to remove her tracheal tube. She was transferred to the postoperative ward for routine observation. Chest x-ray was repeated 6 h later and expansion of both lungs was confirmed (fig. 2). The surgical emphysema resolved gradually and the chest drains were removed after 72 h. Chest x-ray was satisfactory. The patient was discharged from hospital 7 days later. She re-
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on May 30, 2015
CASE REPORT
BILATERAL PNEUMOTHORAX
turned to the hospital for chest x-rays at monthly intervals for 2 months. Her condition remained satisfactory and no other problems were found. DISCUSSION
Bilateral pneumothorax following tracheal intubation and manual ventilation of the lungs in an otherwise healthy patient is extremely rare. Spontaneous pneumothorax may occur in any age group, but is found commonly between 15 and 35 years of age and is commoner in males than females. Approximately 30% of the patients with
FIG. 2. Repeat chest x-ray following insertion of bilateral chest drains with lung expansion.
spontaneous pneumothorax have chronic lung disease, especially bronchitis and emphysema. Traumatic pneumothorax is found in healthy individuals involved commonly in road traffic accidents and is associated usually with other injuries. In our patient none of these factors existed and a diagnosis of iatrogenic pneumothorax was made therefore. Ideally, one should monitor the airway pressure throughout IPPV, but the incident happened where there was little monitoring available in our institution.
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on May 30, 2015
FIG. 1. First chest x-ray, showing bilateral pneumothorax.
339
BILATERAL PNEUMOTHORAX FOLLOWING TRACHEAL INTUBATION C. BISWAS, N. JANA AND S. MAITRA
A 65-yr-old woman weighing 60 kg was admitted to RG Kar Medical College and Hospital, Calcutta, for elective cholecystectomy. Preoperative assessment showed that the patient was otherwise healthy. Heart rate was 80 beat min"1 and regular, arterial pressure 125/80 mm Hg and rate of ventilation 14 b.p.m. Examination of heart and lungs showed no abnormality and the patient's past medical history did not indicate any respiratory disease. Preoperative investigation revealed normal haematology and biochemical values and the electrocardiogram and chest x-ray did not show any abnormality. On the night before the operation, the patient was given diazepam 10 mg by mouth to allay anxiety. Premedication was with pethidine 50 mg and trimeprazine 25 mg i.m 1 h before operation. After pre-oxygenation for 5 min, anaesthesia was induced with thiopentone 3.5mgkg~1. Gallamine 2 mg kg"1 was given and tracheal intubation was performed under direct vision using a size 8 red rubber tracheal tube. Following intubation of the trachea, the lungs were ventilated manually with nitrous oxide 5 litre min"1 and oxygen 3 litre min"1 using a circle system. On auscultation of the lung fields, breath sounds were audible only at the apical regions. Approximately 2 min later, the patient developed cyanosis. Surgical emphysema began to develop on both sides of the neck, chest, abdomen and inguinal regions. Percussion of the chest revealed bilateral hyperresonance. The operation was cancelled. Neostigmine C.BISWAS,* D.A. (ENGL.); N.JANA, D.G.O.(CAL.)> D.A.(CAL.), M.D.(CAL.); S. MAITRA, D.A.(CAL.) M.S.(CAL.); Department of
Anaesthesia, R. G. Kar Medical College and Hospital, Calcutta, India. Accepted for Publication: August 3, 1988. Address for correspondence: 16/14 Beleghata Main Road, Calcutta 700010, India.
SUMMARY An elderly patient undergoing elective cholecystectomy. developed bilateral pneumothorax following intubation of the trachea and manual ventilation of the lungs. Diagnosis was confirmed by chest x-ray and drainage with wide bore cannufae. Drainage of the chest was necessary.
2.5 mg and atropine 1.2 mg were given i.v. to antagonize neuromuscular block and the lungs were ventilated with 100% oxygen. Shallow spontaneous ventilation was established quickly, but the patient remained cyanosed, even though she was breathing 100% oxygen. Cardiac arrest occurred 2 min later. Immediate external cardiac massage was applied and the patient was resuscitated successfully. Sodium bicarbonate 50 mmol litre"1 was given i.v. with hydrocortisone 200 mg. Facilities were not available for analysis of arterial blood, but chest x-ray was performed and showed bilateral collapse of the lungs with massive bilateral pneumothoraces (fig. 1). The diagnosis was confirmed by bilateral insertion of catheters into the pleural cavities. The catheters were connected to closed tube drainage systems and within minutes both lungs expanded and breath sounds were heard on auscultation. A repeated chest x-ray showed expansion of both lungs. The patient's condition improved dramatically and she was able to remove her tracheal tube. She was transferred to the postoperative ward for routine observation. Chest x-ray was repeated 6 h later and expansion of both lungs was confirmed (fig. 2). The surgical emphysema resolved gradually and the chest drains were removed after 72 h. Chest x-ray was satisfactory. The patient was discharged from hospital 7 days later. She re-
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on May 30, 2015
CASE REPORT
BILATERAL PNEUMOTHORAX
turned to the hospital for chest x-rays at monthly intervals for 2 months. Her condition remained satisfactory and no other problems were found. DISCUSSION
Bilateral pneumothorax following tracheal intubation and manual ventilation of the lungs in an otherwise healthy patient is extremely rare. Spontaneous pneumothorax may occur in any age group, but is found commonly between 15 and 35 years of age and is commoner in males than females. Approximately 30% of the patients with
FIG. 2. Repeat chest x-ray following insertion of bilateral chest drains with lung expansion.
spontaneous pneumothorax have chronic lung disease, especially bronchitis and emphysema. Traumatic pneumothorax is found in healthy individuals involved commonly in road traffic accidents and is associated usually with other injuries. In our patient none of these factors existed and a diagnosis of iatrogenic pneumothorax was made therefore. Ideally, one should monitor the airway pressure throughout IPPV, but the incident happened where there was little monitoring available in our institution.
Downloaded from http://bja.oxfordjournals.org/ at University of Birmingham on May 30, 2015
FIG. 1. First chest x-ray, showing bilateral pneumothorax.
339