Iatrogenic Tension Pneumothorax after Fiberoptic-guided Intubation in a Pediatric Patient: A Case Report

@#<p style="text-align: justify;">Fiberoptic-guided intubation (FOI) has been an indispensable component of difficult airway management especially in instances where anatomical limitations precluded use of conventional direct laryngoscopy. Its use, however, is not without risks.<br /><br />This paper presents a 4-year-old female with a limited mouth opening scheduled for an elective oral commissurotomy who developed signs and symptoms of tension pneumothorax immediately following a successful fiberoptic nasotracheal intubation. Passive insufflation of high-flow oxygen through a flexible fiberoptic bronchoscope preloaded with a tight-fitting endotracheal tube led to accumulation of air. This caused lung hyperinflation and subsequently, pneumothorax.</p>

Iatrogenic Tension Pneumothorax after Surgical Tracheostomy in a Child with Idiopathic Subglottic Stenosis: case report / 고신대학교의과대학학술지

Tracheostomy is increasingly performed in children for upper airway anomalies. Here, an 18-month-old child (height 84.1 cm, weight 12.5 kg) presented to the emergency department with dyspnea, stridor, and chest retraction. However, exploration of the airways using a bronchoscope failed due to subglottic stenosis. Therefore, a surgical tracheostomy was successfully performed with manual mask ventilation. However, pneumomediastinum was found in the postoperative chest radiograph. Although an oxygen saturation of 99% was initially maintained, oxygen saturation levels dropped, due to sudden dyspnea, after 3 hours. A chest radiograph taken at this time revealed a left tension pneumothorax and small right pneumothorax. Despite a needle thoracostomy, the pneumothorax was aggravated, and cardiac arrest occurred. Cardiopulmonary-cerebral resuscitation was performed, but the patient was declared dead 30 minutes later. This study highlights the fatal complications that can occur in children during tracheostomy. Therefore, close monitoring, immediate suspicion, recognition, and aggressive management may avoid fatal outcomes.

Tension pneumothorax during peroral endoscopic myotomy for treatment of esophageal achalasia under general anesthesia / Pneumotórax de tensão durante miotomia endoscópica por via oral para tratamento de megaesôfago sob anestesia geral

Abstract More and more endoscopically gastrointestinal procedures require anesthesiologists to perform general anesthesia, such as "peroral endoscopic myotomy". Peroral endoscopic myotomy is a novel invasive treatment for the primary motility disorder of esophagus, called esophageal achalasia. Despite of its minimally invasive feature, there are still complications during the procedure which develop to critical conditions and threat patients' lives. Herein we describe a case about tension pneumothorax subsequent to esophageal rupture during peroral endoscopic myotomy. The emergent management of the complication is stated in detail. The pivotal points of general anesthesia for patients undergoing peroral endoscopic myotomy are emphasized and discussed. Also, intraoperative and post-operative complications mentioned by literature are integrated.

Resumo Cada vez mais os procedimentos gastrointestinais feitos por endoscopia, tais como a miotomia endoscópica por via oral (MEVO), exigem anestesiologistas para administrar anestesia geral. A MEVO é um novo tratamento invasivo para o distúrbio de motilidade primária do esôfago, denominado acalasia esofágica (AE). Apesar de sua característica minimamente invasiva, existem complicações durante o procedimento que evoluem para condições críticas e de risco à vida. Descrevemos aqui um caso de pneumotórax hipertensivo após a ruptura do esôfago durante uma MEVO. O tratamento de emergência da complicação é relatado em detalhes. Os pontos cruciais da anestesia geral para pacientes submetidos à MEVO são enfatizados e discutidos. Além disso, as complicações mencionadas pela literatura nos períodos intraoperatório e pós-operatório são integradas ao texto.

Changes in electrocardiographic findings after closed thoracostomy in patients with spontaneous pneumothorax

OBJECTIVE: We aimed to describe electrocardiographic (ECG) findings in spontaneous pneumothorax patients before and after closed thoracostomy. METHODS: This is a retrospective study which included patients with spontaneous pneumothorax who presented to an emergency department of a tertiary urban hospital from February 2005 to March 2015. The primary outcome was a difference in ECG findings between before and after closed thoracostomy. We specifically investigated the following ECG elements: PR, QRS, QTc, axis, ST segments, and R waves in each lead. The secondary outcomes were change in ST segment in any lead and change in axis after closed thoracostomy. RESULTS: There were two ECG elements which showed statistically significant difference after thoracostomy. With right pneumothorax volume of greater than 80%, QTc and the R waves in aVF and V5 significantly changed after thoracostomy. With left pneumothorax volume between 31% and 80%, the ST segment in V2 and the R wave in V1 significantly changed after thoracostomy. However, majority of ECG elements did not show statistically significant alteration after thoracostomy. CONCLUSION: We found only minor changes in ECG after closed thoracostomy in spontaneous pneumothorax patients.

Development of pulmonary air leak in an extremely-low-birth-weight infant without mechanical ventilation: a case report / 대한마취과학회지

A 34-year-old woman at 25 weeks 3 days was diagnosed with preterm labor and underwent an emergency cesarean section. The neonate did not cry or show any activity. The heart rate was 80 beats/min and the oxygen saturation on pulse oximetry (SpO2) was 77%. Immediately, positive pressure ventilation was delivered by T piece resuscitator, and then anesthesiologist performed endotracheal intubation. The neonate demonstrated severe cyanosis and the SpO2 dropped to 30%. Ventilation was not successful even after intubation, and we found neck crepitus, chest wall distension, and severe cyanosis on physical examination. We suspected tension pneumothorax and performed needle thoracentesis. The neonate was stabilized and transferred to the neonatal intensive care unit for further treatment, but expired on the 10th day of life. We report a case of pulmonary air leak developing tension pneumothorax, pneumomediastinum, subcutaneous emphysema in an extremely-low-birth-weight preterm infant immediately after birth.

Development of pulmonary air leak in an extremely-low-birth-weight infant without mechanical ventilation: a case report / 대한마취과학회지

A 34-year-old woman at 25 weeks 3 days was diagnosed with preterm labor and underwent an emergency cesarean section. The neonate did not cry or show any activity. The heart rate was 80 beats/min and the oxygen saturation on pulse oximetry (SpO2) was 77%. Immediately, positive pressure ventilation was delivered by T piece resuscitator, and then anesthesiologist performed endotracheal intubation. The neonate demonstrated severe cyanosis and the SpO2 dropped to 30%. Ventilation was not successful even after intubation, and we found neck crepitus, chest wall distension, and severe cyanosis on physical examination. We suspected tension pneumothorax and performed needle thoracentesis. The neonate was stabilized and transferred to the neonatal intensive care unit for further treatment, but expired on the 10th day of life. We report a case of pulmonary air leak developing tension pneumothorax, pneumomediastinum, subcutaneous emphysema in an extremely-low-birth-weight preterm infant immediately after birth.

A lethal tension pneumothorax during minimally invasive coronary artery bypass surgery: Can transesophageal echocardiography pick it.

Minimally invasive cardiac surgery is establishing itself as the standard of care across the world. MICS CABG is currently performed in only a few centers. Hemodynamics disturbances are peculiar during MICS CABG due to space constraints. We report a 70‑year‑old man who underwent MICS CABG who developed tension pneumothorax during revascularization that was diagnosed in a novel way.

Double Trouble: A Case of Local Anaesthetic Toxicity Followed By Tension Pneumothorax in a Patient of Marfan Syndrome.

Spontaneous pneumothorax in patients with Marfan syndrome is common. Even a small pneumothorax can become a tension pneumothorax under positive pressure ventilation. Sometimes anaesthesiologists have to cater to more than one complication intraoperatively. Thorough knowledge of the subject and availability of monitors and anaesthesiologist in the operation theater as in general anaesthesia during locoregional anaesthesia is mandatory to avoid occurrence of catastrophy.

Evaluation of the Optimal Site and Needle Length of Needle Thoracostomy in Chest Trauma Patients

PURPOSE: Tension pneumothorax is a life threatening condition. As an emergency treatment, needle thoracostomy with 50mm angiocatheter at the second intercostal space on the mid-clavicular line (2nd ICS/MCL) is recommended in the current guidelines. However, another site has been suggested in some studies. The purpose of this study was to determine whether the current procedure should be changed, by comparing the chest wall thicknesses (CWT) at the 2(nd) ICS/MCL and the 5(th) ICS/AAL (anterior axillary line) of injured patients. METHODS: A retrospective observational study was performed in an emergency center between May 2009 and December 2011. Medical records and computed tomography (CT) images of 140 included patients were reviewed. CWT at the 2(nd) ICS/MCL was compared with the 5(th) ICS/AAL. Moreover, the relationship between BMI (body mass index) and CWT was evaluated. RESULTS: CWT of the 2(nd) ICS/MCL was 31.7±8.5 mm on the right and 31.6±8.8 mm on the left, with no differences (p=0.42). CWT of the 5(th) ICS/AAL was 28.1±8.5 mm on the right and 27.8±7.7 mm on the left, also with no differences (p=0.30). CWT of the 2(nd) ICS/MCL was thicker than that of the 5(th) ICS/AAL (p<0.001). Nevertheless, CWT of all sites were not thicker than 50 mm (p<0.001). BMI was positively correlated with CWT. CONCLUSION: There was insufficient amount of evidences shown in this study to change the current guidelines of needle thoracostomy. However, in case of obvious patients, a long needle and 5(th) ICS/AAL site should be considered for needle thoracostomy, because CWT tended to increase as BMI increased.

Do mannequin chests provide an accurate representation of a human chest for simulated decompression of tension pneumothoraxes? / 世界急诊医学杂志（英文）

BACKGROUND: Tension pneumothorax (TPX) is an uncommon but life-threatening condition. It is important that this uncommon presentation, managed by needle decompression, is practised by paramedics using a range of educationally sound and realistic mannequins. The objective of this study is to identify if the chest wall thickness (CWT) of training mannequins used for chest decompression is an anatomically accurate representation of a human chest. METHODS: This is a two-part study. A review of the literature was conducted to identify chest wal thickness in humans and measurement of chest wal thickness on two commonly used mannequins. The literature search was conducted using the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE databases from their beginning until the end of May 2012. Key words included chest wall thickness, tension pneumothorax, pneumothorax, thoracostomy, needle thoracostomy, decompression, and needle test. Studies were included if they reported chest wal thickness. RESULTS: For the literature review, 4461 articles were located with 9 meeting the inclusion criteria. Chest wall thickness in adults varied between 1.3 cm and 9.3 cm at the area of the second intercostal space mid clavicular line. The Laerdal? manikin in the area of the second intercostal space mid clavicular line, right side of the chest was 1.1 cm thick with the left 1.5 cm. The MPL manikin in the same area or on the right side of the chest was 1.4 cm thick but on the left 1.0 cm. CONCLUSION: Mannequin chests are not an accurate representation of the human chest when used for decompressing a tension pneumothorax and therefore may not provide a realistic experience.

Aumento del volumen espirado como signo precoz de neumotórax a tensión: Informe de cuatro casos / Increase of the exhaled volume as an early sign of tension pneumothorax: Inform of four cases

Introducción: El neumotórax a tensión es una temible complicación perioperatoria asociada a elevada morbimortalidad y con mayor incidencia durante procedimientos videolaparoscópicos, debido al uso de neumoperitoneo. Objetivo: Analizar la evolución de cuatro pacientes que desarrollaron neumotórax a tensión como complicación intraoperatoria de un procedimiento videolaparoscópico con anestesia general. Desarrollo: Fueron monitorizados básicamente los pacientes programados para operación de vagotomía altamente selectiva anterior y vaguectomía troncular posterior por videolaparoscopia realizada con anestesia general balanceada. Inducidos por el aumento súbito del volumen espirado como primera alteración, se estableció el diagnóstico clínico de neumotórax a tensión por paso de dióxido de carbono intrabdominal a la cavidad pleural derecha. Se observó además la modificación secundaria de otros parámetros como tensión arterial, saturación periférica de oxígeno y concentración periódica final de dióxido de carbono, lo cual permitió practicar rápidamente el tratamiento de esta grave complicación intraoperatoria. Conclusiones: El aumento del volumen espirado puede inducir precozmente la sospecha clínica de neumotórax a tensión, lo cual favorece su tratamiento inmediato.

Tension pneumothorax is a fearsome perioperative complication associated with a high morbidity and with a great incidence during the video-laparoscopic procedures due to the use of pneumoperitoneum. Objective: To analyze the evolution of four patients presenting with tension pneumothorax as a intraoperative complication of video-laparoscopic procedure with general anesthesia. Development: Basically the patients programmed for a highly selective anterior vagotomy and posterior truncal vagotomy operation carried out with general anesthesia were monitored. Due to the sudden increase of exhaled volume as the first alteration, the diagnosis of tension pneumothorax by passing of intra-abdominal carbon dioxide to the right pleural cavity was made. Also, there was a secondary modification of other parameters as arterial tension, oxygen peripheral saturation and carbon dioxide final periodic concentration, allowing us to apply quickly the treatment of this intraoperative and severe complication. Conclusions: The increase in the exhaled volume may the early to induce the clinical suspicion of tension pneumothorax favoring its immediate treatment.

Bilateral tension pneumothorax caused by an abrupt increase in airway pressure during cervical spine surgery in the prone position: A case report / 대한마취과학회지

Elevated peak inspiratory airway pressure (PIP) can occur during general anesthesia and is usually easily rectified. In rare circumstances it can lead to potentially fatal conditions such as tension pneumothorax. We report on a 77-year-old male patient admitted for a cervical laminoplasty. The preoperative chest radiograph showed normal findings and there was no medical history of allergy or underlying airway inflammation. Anesthesia induction and maintenance progressed uneventfully. However, 5 minutes after prophylactic antibiotic administration, PIP suddenly increased and blood pressure dropped. The operation was abandoned and the patient was moved to a supine position to perform chest radiography. Cardiac arrest occurred, and cardiopulmonary resuscitation was performed. The radiograph showed bilateral tension pneumothorax. Needle aspiration was immediately performed, and chest tubes were inserted. Ventilation rapidly improved and the vital signs normalized. The patient was discharged without sequelae on postoperative day 36.

Tension pneumothorax in a newborn after Cesarean-section delivery: A case report / 대한마취과학회지

Tension pneumothorax in newborns is a rare but life-threatening complication. We encountered a case of a full-term neonate with a breech presentation. An elective cesarean section was scheduled. Immediately after delivery, the newborn was found to be breathless with a heart rate <60/min. During intubation and cardiac massage, the patient's femoral artery and vein were accessed. The infantogram revealed a right side tension pneumothorax. A 22 gauge needle thoracentesis relieved the right side chest pressure and a closed thoracostomy was performed. The severe acidosis was corrected with sodium bicarbonate. The patient was managed in the neonatal intensive care unit, but died from uncorrectable acidosis. We report this case with a review of the relevant literature.

Cardiac arrest induced by tension pneumothorax during ventilating bronchoscopy: A case report / 대한마취과학회지

Tension pneumothorax during ventilating bronchoscopy for foreign body removal is a rare but life-threatening complication. The authors present a case of cardiac arrest caused by tension pneumothorax in a 9-month-old girl who underwent ventilating bronchoscopy for foreign body (peanut) removal. Tension pneumothorax was due to tracheobronchial lacerations caused by a bronchoscope. The patient was successfully resuscitated by cardiopulmonary resuscitation and chest tube insertion. The airway injury was effectively repaired by thoracotomy under extracorporeal membrane oxygenation.

Tension pneumothorax after arthroscopic shoulder surgery: A case report

While arthroscopic shoulder surgery is considered relatively safe, complications have been reported.Though rare, pneumothorax has been reported in patients undergoing arthroscopic shoulder surgery.Tension pneumothorax must be immediately recognized and treated due to its potentially life threatening consequences.The authors present a case of a patient who developed tension pneumothorax after arthroscopic shoulder surgery, and its anesthetic managements.

Tension pneumothorax occurred by tumescent solution injection during delay extended latissimus dorsi flap : A case report

Tension pneumothorax is known as a rare complication of breast augmentation surgery, but can occur more than expected. This is a case of a 34-year-old woman who was to receive delay extended latissimus dorsi flap under general anesthesia. The patient was injected the tumescent solution by 25 gauge spinal needle preoperatively. In the course of operation, the peak inspiratory pressure was increased gradually. At the moment of changing the position from supine to sitting position, the blood pressure decreased to 75/45 mmHg. We took the chest radiography, which showed typical findings of tension pneumothorax of right side. Prompt needle aspiration and chest tube insertion relieved tension pneumothorax. The patient's vital signs got stabilized and there was no visible remained pneumothorax at following chest radiography taken. We should pay attention to the possible occurrence of devastating pneumothorax during breast augmentation surgery, especially local infiltration using long needle is performed.

Opioid-induced Muscle Rigidity with a Delayed Manifestation Misunderstood as a Tension Pneumothorax: A case report / 대한통증학회지

Opioid-induced rigidity is a potentially life-threatening complication that can occur after treatment with large doses of opioids, but with early recognition it can be treated effectively with naloxone or with muscle relaxants. Regarding its onset time, there have been few case reports that have described delayed manifestations of opioid-induced rigidity. The mechanism of this complication is not well understood. In this report we describe a case of incidental overdose injection of sufentanil and subsequently review the confusing clinical features that require immediate diffenrentiation and the possible mechanim of this complication.

Delayed Tension Pneumothorax Detected 4 Days after Central Venous Catheterization: A case report / 대한마취과학회지

Pneumothorax is one of the most frequent complications of percutaneous central venous catheterization.Most significant pneumothoraces are easily detected on postcatheterization chest radiograph.However, we report a rare case of delayed tension pneumothorax detected 4 days after unsuccessful central venous catheterization via the infraclavicular subclavian vein, although initial postcatheterization and postoperative supine chest radiographs showed no active lesion.

Anesthetic Management of a Patient with Complete Tracheal Transection by Blunt Trauma: A case report / 대한마취과학회지

Tracheobronchial rupture due to blunt chest trauma is an uncommon injury and the clinical presentations are variable. Recently, the incidence of tracheobronchial injuries has increased with the increase in traffic accidents and mechanization.The early diagnosis and primary repair of tracheobronchial rupture not only restores normal lung function, but also avoids the difficulties and complications associated with delayed diagnosis and repair.We report our clinical experience in anesthetic management of a patient with complete tracheal transection suffering from progressive dyspnea, subcutaneous emphysema in the neck and anterior chest wall, and bilateral tension pneumothorax.The literature regarding accidental tracheal injuries will be reviewed.

Tension Pneumothorax Following Open Cholecystectomy Under General Anaesthesia

We report a case of tension pneumothorax developing in the immediate post operative period following open cholecystectomy.