Anesth Analg 2008; 106:1590-
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e31816b5383
LETTER TO THE EDITOR
Section Editor:
Lawrence Saidman
Tension Pneumothorax During One-Lung Ventilation
Jens Lohser, MD, MSc, FRCPC
Anesthesiology, Pharmacology and Therapeutics Department; University of British Columbia; British Columbia, Canada; jens.lohser{at}vch.ca
To the Editor:
The reported case of a tension pneumothorax during pneumonectomy by Finlayson et al. raises a number of issues related to the use of right-sided double-lumen tubes (DLTs) as well as that of a different presentation in the setting of an open hemithorax.1 First, right-sided DLTs are more difficult to place because of the need to line up the lateral bronchial orifice with the right upper lobe (RUL) take-off and clinical placement of right DLTs has been shown to result in malposition in 73%–89% of cases.2,3 This malposition rate may potentially be decreased when using a modified DLT,4 however fiberoptic confirmation is mandatory for exact tube placement, particularly when relying on the RUL for ventilation as during right one-lung ventilation (OLV). Proceeding with a right OLV case without fiberoptic confirmation of patency of the RUL take-off is likely to have been the cause of the pneumothorax in this case of OLV in a patient with no underlying lung disease.
Second, a sudden increase in airway pressure during OLV is often due to partial airway obstruction. With a left DLT, it may indicate left upper lobe obstruction during left OLV or bronchial cuff herniation during right OLV. With a right DLT, it may indicate RUL obstruction during right OLV or bronchial cuff herniation during left OLV. Bronchoscopic confirmation of DLT position, including patency of the RUL orifice, should therefore immediately be performed, along with resuming two-lung ventilation if necessary.
Third, tension pneumothorax should in most cases be a rather simple diagnosis during open thoracotomy as any expansion of the dependent hemithorax pushes the mediastinum towards the operating surgeon. In addition to the facility of diagnosing a tension pneumothorax, the surgeon is also in a unique position of easy access to the dependent hemithorax for decompression. The anterior pleural reflection of the dependent lung is readily accessible across the anterior retrosternal mediastinum and can be opened for immediate decompression, stabilizing the patient for eventual chest tube placement.
REFERENCES
- Finlayson GN, Chiang AB, Brodsky JB, Cannon WB. Intraoperative contralateral tension pneumothorax during pneumonectomy. Anesth Analg 2008; 106:58–60[Abstract/Free Full Text]
- McKenna MJ, Wilson RS, Botelho RJ. Right upper lobe obstruction with right-sided double-lumen endobronchial tubes: a comparison of two tube types. J Cardiothorac Anesth 1988;2:734–40[Medline]
- Klein U, Karzai W, Bloos F, Wohlfarth M, Gottschall R, Fritz H, Gugel M, Seifert A. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology 1998;88:346–50[Web of Science][Medline]
- Bussières JS, Lacasse Y, Côté D, Beauvais M, St-Onge S, Lemieux J, Soucy J. Modified right-sided Broncho-Cath double lumen tube improves endobronchial positioning: a randomized study. Can J Anaesth 2007;54:276–82[Web of Science][Medline]
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