Kamal, R S

Zaidi, A

Zubair, N A

English

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eCommons@AKUDepartment of Anaesthesia Medical College, PakistanJune 1997Bronchospasm/desaturation under anaesthesia: arethey signs of pneumothorax?N A. ZubairA ZaidiR S. KamalFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesia and Analgesia Commons, and the Anesthesiology CommonsRecommended CitationZubair, N. A., Zaidi, A., Kamal, R. S. (1997). Bronchospasm/desaturation under anaesthesia: are they signs of pneumothorax?. Journalof Pakistan Medical Association, 47(6), 174-176.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_anaesth/189Bronchospasm/Desaturation Under Anaesthesia: Are They Signsof Pneumothorax?Pages with reference to book, From 174 To 176 Naeem A. Zubair, Asif Zaidi, Rehana S. Kamal ( Department of Anaesthesia, The Aga Khan University Hospital, Karachi. ) Introduction The incidence of iatrogenic pneumothorax has increased as a result of aggressive invasive monitoringprocedures, new modes of mechanical ventilation and invasive diagnostic/therapeutic techiques. Thediagnosis of pneumothorax under anaesthesia can be difficult due to poor clinical manifestation (onlysigns may be cardiovascular changes, decreased oxygen saturation, or wheezes). If it is not diagnosedearlier and treated1, it can lead to high mothidity and mortality. We are reporting two unusual cases ofpneumothomx which occurred in otherwise healthy patients.Case Report Case 1A 60 years old lady with a lump in her left breast which gradually increased in size over the last twoyears was admitted for modified radical mastectomy. Pre-operative assessment revealed an averageheight and body weight of 72 Kg. Physical examination did not reveal any systemic abnormality. Shewas normotensive, non-asthmatic and non-diabetic. All laboratoiy investigations, E.C.G. and X-rayschest were within normal limits. She was classified as ASA 11 because of relative obesity. The patientwas advised a standard premedication of tab. midazolam 7.5 mg orally 2 hours before surgery. In theoperating room, triple monitoring (non-invasive blood pressure, ECG and pulse oximetery) was started.She was induced with Thiopental sodium 4-5 mg/kg B. Wt. and tracheal intubation was facilitated withsuccinylcholine (1.5 mg/Kg B. Wt.). Patient was then placed on control mode of ventilation using IPPVon Siemen 710 ventilator, with a tidal volume of 650 ml and at a rate of 10/minute. Anaesthesia wasmaintained with a mixture of oxygen/N2O (40-60%) and halothane (0.5-1%). Relaxation wasmaintained with pancuronium bromide (1-2 mg on Pm bases) while analgesia was provided withintravenous pethidine (1 mg/Kg). Haemodynaniic parameters e.g. blood pressure (130/90 mm Hg) andheart rate (65/minute) increased temporarily at intubation and then stabilised towards the baselinevalues. Peak airway pressures were 25 cmH2O at this stage. Before proceeding with the surgery, it wasdecided to take a core needle biàpsy from the breast lump. The surgical resident made three attempts totake the tissue with the help of Trucut biopsy needle (Baxter Travenol 14G, 4/1/2 inches long). Fiftyminutes after the biopsy, a sudden decrease in the tidal volume (from 650 to 550 ml) and a significantincrease in peak airway pressures (from 25 cmH2O to 40-45 cmH2O was noticed. At this stage bloodpressure rose to 155/108 mniHg, pulse rate went upto 125/minute and SaO2 decreased to 95% from 99-100%. Auscultation revealed presence of wheezes only on the right side. Left side could not beauscultated because of surgical field. A provisional diagnosis of bronchospasm was made and treatmentwas started with intravenous aminophylline (Bolus of 250 mg plus a continuous infusion at a rate of 0.6mg/kg/hour). The wheezing sounds diminished and the air entry in the right side appeared to haveimproved. Still the airway pressures remained high ( more than 40 cm ,H20). At this stage, to preventbaroirauma, it was decided to change the respiratory parameters. Tidal volume was decreased from 650to 450 ml and the respiratory rate increased from 10 to 15 breaths/minute. The airway pressureremained below 40 cm H2O after these changes. Patient remained tachycardic and hypertensive duringmajor part of the surgical time. When the resectionof breast tissue was completed, the surgical field wasirrigated with normal saline, air bubbles were detected which were coming Out of a small hole in thechest wall. There was no surgical emphysema. A diagnosis ofiatrogenicpneumothorax was made and achest tube was passed before closing the wound. Withthe insertion of the chest tube, the blood pressure,heart rate and airway pressures came back towards normal baseline values. Oxygen saturationimproved and became 99-100%. The patient was reversed with standard doses of atropine andprostigmine and extubated. A portable X-rays in the recovery room showed fuily expanded lungs andchest tube in proper position. Patient remained stable haemodynamically inthe recovery room and wasshifted to the ward with the chest tube in-situ. She was discharged home 10 days after her stay in thehospital.Case 2A 52 years old lady came to the hospital with the complaints of feeling of heaviness, pain andappearance of a lump inherrightbreast. She was admitted for modified radical mastectomy also.Preoperative assessment revealed a non-diabetic, non-asthmatic and normotensive patient with normalECG, chest X-rays and biochemistry. She was graded as ASA 11 because of her relative obesity (height153 cm and body weight 70 Kg). A standard oral premedication of tab. midazolam7.5 mgwasgiven2hours before surgery. Thebasic triple monitoring (non-invasive blood pressure, ECG and pulseoximetery) was started before induction while capnograph was attached aftertracheal intubation. Patientwas induced with Thiopental Sodium (4-5 mg/Kg I.V.). Trachea was intubated with a portex Et tube of7.5 size. Muscle relaxation was achieved with pancuronium bromide (0.1 mg/Kg). Patient’s lungs wereventilated with a mixture of Oxygen/N2O (40/60%) and halothane (0.5-1%). Intravenous Pethidine (1mg/Kg) was given for analgesia. Patient was placed on a control mode of ventilation (IPPV) usingServo-Manley MS 2000 Ventilator. The biopsy of the lump was taken by a resident using Trucut biopsyneedle (Baxter Travenol 14 G, 4-1/2 inches long). The surgical procedure for modified radicalmastectomy was started and it lasted for three and a half hours while duration of anaesthesia was aboutfour hours. The intraoperative course was unremarkable. She remained haemodynamically stable,normocapnic and well oxygenated (SaO2 98-99%). At the end of surgery muscle relaxation wasreversed by giving standard doses of reversal drugs (atropine plus prostigmine) and patient’s tracheaextubated. In the recovery room pulse oximeter showed a SaO2 of 86-87%, while blood pressure andheart rate was normal. Oxygen flow was increased from 4L/minute to 10 L/minute via face mask.Temporarily the oxygen saturation improved upto 92%. After 15 minutes the saturation again droppedto. 89% and there was no improvement despite an increase of oxygen flow rate to 15L/minute. Thepatient was stable haemodynamically. On clinical examination, there was markedly decreased air entryon the right side. There was no surgical emphysema. An x-ray chest was advised which showed a rightsided pneumothorax. A chest tube was inserted and air gushed out of the tube. Oxygen saturationimproved immediately (SaO2 99%). Rest of her stay in the recovery room and hospital remaineduneventful.Discussion During the last decade the incidence of iatrogenic pneumothomx has increased as a result of invasion ofmajor vessels for monitoring, prolonged mechanical ventilationand external cardiac massage2. Newmethods of diagnostic and therapeutic procedures such as percutaneous liver and renal biopsy,laparoscopy, amniocentesis, has resulied in new causes of pneumothorax3. The incidence ofpneumothorax is l%during invasive momtonng4, 14%inthepatientswhowere treated with high levels ofPEEP during controlled ventilation5, while it is 8-10% when percutaneous needle aspiration biopsy oflung was done6. The clinical presentation of pneumothorax is dependent upon the patient’s level ofconsciousness, associated cardiopulmonary condition and age3. Detection of pneumothomx in theanaesthetized patient is a very difficult task, as it may mimic that of bronchospasm or as non-specificcardiovascular changes. The frequent earlier signs might be tachycardia, hypotension, increased airwaypressures, wheezes, pmgressive hypoxia and cardiac arrhythinias4,7. In our first patient, the signs wereincreased airway pressures, decreased tidal volume, decreased air entry, wheezes, decreased oxygensaturation, tachycardia and hypertension. A misdiagnosis ofbronchospasm was made and treated.Misdiagnosis is not un- common underanaesthesia as beth the conditions may present with similarsigns. Delay in diagnosis could be dangerous and may result in a fatal out-come3. In our second patientthe only sign was decreased oxygen saturation as detected on pulse oximetery in the recovery room.This hypoxia was refractory to the increase in flow of oxygen fmm 4 to 1 5L/minute. Pneumothomxmust be considered if there is unexplained cardio-respiratory detenoration4, in the recovery room3.Desaturationas detected by pulse oximetery must alert the anaesthetist about the possibility ofpneumothorax4 especially if a pneumothorax prone procedure hasbeendone onthe patient.Inbothourcases small open type pneumothoraces occurred due to the Trucut biopsy needle. Insertion ofa chest tube before closure of the surgical wound treated the problem in case 1. In the second patient,no significant problems were encountered during anaesthesia and surgery. The reason for trouble freeanaesthesia course might be due to the fact that it was a small open type Pneumothorax. In a report ontwo cases undergoing laparoscopic fundoplication, workers suspected pneumothomx due to minorreduction in oxygen saturation8. They did not face any other significant problems until musclerelaxation was reversed and spontaneous respiration allowed to resume as was the case inQurpatient.Pulse oximeteiy could detect the initial sign of pneumothorax prior to haemodynaniic instability’. Inour second patient desaturation and refractory hypoxia without haemody namic instability was due to adelayed pneumothorax. The open type of pneumothorax was probably converted into pneumothoraxtype 11 due to closure of the external outlet at the muscle and skin level. The discontinuation of IPPV,reversal of muscle relaxation and return of spontaneous respiration might have enlarged thepneumothomx/collapse of the lung due to the changes in the intrapleural pressure from a mean positiveto a mean negative. Based onour cases and review of the literature we suggest that if there isunexpected and unexplained desaturation/bronchospasm intraopemtively or in the postoperative period,pneumothorax should be suspected. It should be highon the list of differential diagnosis especially ifthe patient has undergone a pneumothorax prone procedure. We also recommend that the patients withincreased chances of iatrogenic pneumothorax should be monitored for ECG, blood pressure, pulseoximeteiy and airway pressures. Also we should consider avoidance of nitrous oxide in such cases. Thebiopsy’should be takenby an expert person only. Multiple attempts to get the biopsy by a junior surgeonshould be discouraged.References 1. Kanaya, N.. Tanaka, K., Igarashi, M. et al. Intraoperative delayed pneumot. horax after subclavianvein catheterisation. Masui. 1 993;42:I 08-Ui.2. Steier, M., Ching, N., Roberts, E.B. et al. Pneumothorax complicating continuous ventilatorysupport. J. Thorac. Cardiovasc. Surg., 1 974;1 7:67-69.3. Denlinger, J.K. Pneuxnothorax: Complications in Anaesthesiology (Edit) Orkin, EK. andCoopennan, L.H. Philadelphia (USA), J.B. Lippincott Co., 1983, pp. 173-182.4. Williamson, J.A., Webb, R.K., Van-Der Walt, J.H. etal. TheAustralian incident monitoring study.Pneumothorax: An analysis of 2000 incident reports. Anaesth. Intensive Care, 1993;2 1:642- 645.5. ‘Kirby, R.R.. Downs, J.B., Civetta, J.M. et al. High level positive end expiratory pressure (PEEP) inacute respiratory insufficiency. Chest, 1 975;67: 156-1 58.6. Ribichini, P., Solaini, L., Montanan, M.C. eta!. Percutaneous needleaspiration biopsy in intrathoracicLesions. Minerva Chin., 1 992;47: 1541-1 544.7. Botz, G. and Brock-Utne, J.G. Are electrocardiogram changes the first signs of impendingperioperative pneumothorax. Anaesthesia, 1 992;47: 1057-1059.8. Hanning, C.D. and Veitch, P. S. Pneumothorax and laparoscopic fundoplication. Anaesthesia,1995;50:1099-2000.

Bronchospasm/desaturation under anaesthesia: are they signs of pneumothorax?

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Bronchospasm/desaturation under anaesthesia: are they signs of pneumothorax?

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