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Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 217-219

Management of intraoperative bilateral spontaneous pneumothorax during neurosurgery: Importance of point-of-care ultrasonography

Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission30-Aug-2021
Date of Acceptance12-Oct-2021
Date of Web Publication13-Nov-2021

Correspondence Address:
Dr. Manbir Kaur
Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_51_21

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How to cite this article:
Bansal R, Narayanan B, Kaur M, Chhabra S. Management of intraoperative bilateral spontaneous pneumothorax during neurosurgery: Importance of point-of-care ultrasonography. Airway 2021;4:217-9

How to cite this URL:
Bansal R, Narayanan B, Kaur M, Chhabra S. Management of intraoperative bilateral spontaneous pneumothorax during neurosurgery: Importance of point-of-care ultrasonography. Airway [serial online] 2021 [cited 2022 Dec 5];4:217-9. Available from: https://www.arwy.org/text.asp?2021/4/3/217/330384

Intraoperative bilateral spontaneous pneumothorax (IBSP) is an infrequent but potentially fatal complication which if left undiagnosed or not treated promptly will result in high mortality.[1],[2] IBSP usually occurs in the setting of an underlying lung disease including emphysematous bullae, pleural blebs and cavities due to pulmonary tuberculosis which might rupture causing tension pneumothorax.[3] We report an interesting case of IBSP which was managed successfully with the help of point-of-care ultrasound in a patient undergoing a neurosurgical procedure.

A 22-year-male, a known case of tuberculous meningitis with communicating hydrocephalus on antitubercular treatment and a right ventriculoperitoneal shunt in situ, presented to the emergency department of our institute. He complained of diplopia and gradual bilateral visual loss for the past 20 days with Glasgow Coma Scale score of E4V5M6. Physical examination was unremarkable with no history of smoking. Routine laboratory investigations including full blood count, renal and liver function tests were within normal limits. Chest X-ray was normal. Contrast-enhanced magnetic resonance image brain showed multiple dural-based contrast-enhancing lesions in the right temporoparietal region with oedema and mass effect. Right decompressive hemicraniectomy and dural biopsy were planned under general anaesthesia.

Anaesthesia was induced with propofol (2 mg/kg) and fentanyl (2 μg/kg). Muscle relaxation was achieved with rocuronium (0.6 mg/kg). The airway was secured using an 8.0 mm ID endotracheal tube which was fixed at the 22 cm mark. After confirming correct tube placement, the patient was placed on volume control mode with a tidal volume of 6 mL/kg, respiratory rate 14/min and positive end-expiratory pressure of 5 cm H2O. The airway pressure was maintained at 16–18 cm H2O. Vital signs were recorded – blood pressure 130/70 mm Hg, heart rate 110/min, oxygen saturation (SpO2) 100% and end-tidal carbon dioxide concentration (ETCO2) of 34 mm Hg. Surgery started and following dural opening, the patient developed a sudden fall in saturation from 100% to 60% with a fall in BP to 80/56 mm Hg. The capnogram started to show a decline from 34 mm Hg to 18 mm Hg. The surgeons were informed immediately. As saturation had dropped after opening of the dura, venous air embolism was suspected and a wet mop was placed on the surgical site by the surgeons. All ventilator connections were checked and correct placement of the endotracheal tube was reconfirmed. There was a slightly decreased air entry on the left hemithorax as compared to the right. Endobronchial placement of the tube was ruled out. We called for help and several anaesthesiologists responded, making more hands available for dealing with the critical situation. Many tasks were performed simultaneously. A senior anaesthesiologist immediately inserted a central venous catheter into the right subclavian vein under ultrasound guidance. Aspiration of the catheter was negative for air. A second anaesthesiologist performed needle thoracocentesis to rule out tension pneumothorax which was also negative. A third member performed point-of-care ultrasonography (USG) of the lung with an ultrasound machine (LOGIQe, GE, China) using a linear transducer probe. It revealed a lung point and stratosphere sign on the left side of the lung suggestive of tension pneumothorax [Figure 1]. Intercostal drainage (ICD) tube was inserted on the left side. Blood pressure and saturation improved. Repeat lung ultrasound revealed a seashore sign indicating normal lung and surgery was allowed to proceed. However, within a few minutes, the patient again started desaturating and developed hypotension and a decline in ETCO2. Auscultation and point-of-care USG revealed right-sided tension pneumothorax. An ICD tube was inserted immediately on the right side, and the repeat ultrasound was normal. The patient's saturation, blood pressure and ETCO2 normalised once again. The surgical procedure was completed and the patient was shifted to the intensive care unit (ICU) for mechanical ventilation. The patient remained haemodynamically stable for 2 days in ICU and the ICDs were removed.
Figure 1: Ultrasound images of lungs (M mode). Left side shows seashore sign (normal lung sliding) and right side depicts lung point and stratosphere sign (seen in pneumothorax)

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Tension pneumothorax during general anaesthesia is a rare condition. The primary risk factor for developing pneumothorax during general anaesthesia is positive pressure ventilation as it increases the risk of barotrauma. The presence of emphysematous bullae or more minor blebs is a well-known situation in which pneumothorax develops with positive pressure ventilation.[4] In our patient, the preoperative chest radiograph was normal. We cannot, therefore, confirm or exclude the presence of emphysematous bullae that ruptured resulting in a pneumothorax. Another rare factor that might increase the risk of developing pneumothorax is excessive airway manipulation during tracheal intubation which was also not the case in our patient.

In most cases, the diagnosis of pneumothorax during anaesthesia is that of exclusion because most of the signs are non-specific. Regardless of the cause, early recognition and management are crucial to prevent unfavourable outcomes.[5] Point-of-care ultrasound plays an important role in the diagnosis of pneumothorax.[6] Although many other modalities are available for the diagnosis of pneumothorax such as chest X-ray and computed tomography (CT) of the chest,[7] ultrasound is more advantageous as it is portable, does not produce harmful radiation and is more sensitive than chest X-ray while maintaining similar specificity.[8] In comparison with chest CT where the patient has to be moved to the radiological suite, USG can be done by the bedside in the operation theatre.[8] The initial management of maintaining a stable patient should happen simultaneously while diagnosing the main problem. The definitive management of pneumothorax is the insertion of an intercostal tube.

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Ueda K, Ahmed W, Ross AF. Intraoperative pneumothorax identified with transthoracic ultrasound. Anesthesiology 2011;115:653-5.  Back to cited text no. 5
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Husain LF, Hagopian L, Wayman D, Baker WE, Carmody KA. Sonographic diagnosis of pneumothorax. J Emerg Trauma Shock 2012;5:76-81.  Back to cited text no. 8
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