Tension Pneumothorax During One-Lung Ventilation

Abstract

In Response: Our intent in submitting this case report was to highlight the pathophysiology and early clinical signs of a tension pneumothorax in the setting of an open contralateral thorax. Dr. Lohser1 reiterates established literature that defines the challenges confronted with lung isolation with a right-sided double-lumen tube (DLT). Experienced clinicians can safely institute functional lung isolation without the assistance of fiberoptic bronchoscopy with a left-sided DLT.2 The greater margin of safety with a left-sided DLT is due to the distal take-off of the left upper lobe orifice.3 We agree that successful placement of a right-sided DLT requires fiberoptic bronchoscopy and visualization of a patent right upper lobe orifice.4 DLT malposition is commonly responsible for increasing airway pressures during one lung ventilation. However, bronchospasm, secretions, dynamic hyperinflation, and pneumothorax must also be considered as potential causes. Fixating attention on just tube malposition may distract from the diagnosis and delay timely treatment of these other serious causes. The “classic” presentation of a tension pneumothorax during an open thoracotomy is herniation of the mediastinum into the operative field. This phenomenon was not observed in our patient. From the surgeon's vantage this case appeared as a failure of lung isolation since “normal” appearing lung obscured the operative field. Displacement of the mediastinum would only be appreciated if the operative lung was collapsed and the open hemithorax inspected before the pneumothorax expanded. In our case with its unique presentation, the risk of significant complications from decompressing the contralateral pleural space with a needle directed through the operative field (e.g., normal lung) would have been unacceptable. Gordon N. Finlayson, MD, FRCP Jay B. Brodsky, MD Department of Anesthesia Stanford University School of Medicine Stanford, California [email protected]