The development of tension pneumothorax during mask ventilation under general anesthetic induction.

Abstract

Elevated peak inspiratory pressure (PIP) can cause pulmonary barotrauma during general anesthetic induction [1]. However, in patients who have bulla, tension pneumothorax can occur even if PIP is not highly elevated. We report a case of tension pneumothorax which occurred during anesthetic induction. The patient was a 67-year-old male scheduled for video-assisted thoracoscopic (VATS) bullectomy. He weighed 45 kg and was 163 cm tall. He was diagnosed with the human immunodeficiency virus (HIV) prior to pneumocystis pneumonia. His medical history included atrial fibrillation and chronic obstructive pulmonary disease (COPD). Physical examination revealed crackles and coarse lung sounds in both fields. Preoperative arterial blood gas analysis in room air showed a hydrogen ion concentration (pH) of 7.50, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mmHg, a partial pressure of arterial oxygen (PaO2) of 71 mmHg, and an arterial oxygen saturation (SaO2) of 96%. Radiologic findings showed a sizeable cyst which had recently developed in the right lower lobe (Fig. 1). Pulmonary function test presented severe obstructive pattern possibly combined with restriction: predicted percentage of Forced expiration value after 1 second (FEV1) was 28%, predicted percentage of forced vital capacity (FVC) was 75%, and FEV1/FVC ratio was 28%. He arrived at the operating room without premedication. The vital signs prior to anesthetic induction were as followes: a blood pressure of 110–115/55–60 mmHg, an atrial fibrillation rhythm with a heart rate about 90 beats/min, and a peripheral oxygen saturation (SpO2) of 94% in room air. The left radial artery was cannulated with a 20-gauge catheter for continuous monitoring of systemic blood pressure. After preoxygenation, we administered 2% propofol with the Master target-controlled infusion (Orchestra Ⓡ Base Primea; Fresenius-MCM GmbH, Germany) after administration of lidocaine (40 mg). After confirming loss of consciousness, we administered rocuronium (0.5 mg/kg), and remifentanil TCI was started. Assisted and controlled ventilation using mask and reservoir bag with O2 6 L/min was applied. Airway pressure release valve was set in 20 cmH2O and PIP was maintained below 20 cmH2O during ventilation.