Tension pneumothorax (TPT) occurs when air accumulates in the pleural space, leading to lung collapse, pulmonary artery shunts, hypoxemia, and hemodynamic collapse[1]. This case illustrates the importance of teamwork and communication, with a focus on chest tube management for timely detection and treatment of TPT.
A 60-year-old woman with a history of smoking, hypertension, AIDS, and hepatitis C with recurrent pneumonia and local exudative pleural effusion. She underwent thoracentesis, pleural biopsy, chemical pleurodesis, and left thoracoscopic decortication complicated by parenchymal hemorrhage requiring a thoracotomy.
Sudden difficulties in ventilation and oxygenation were noted during mechanical ventilation during repositioning from lateral to supine position. Peak airway pressure, hypoxemia, tachycardia, and refractory hypotension, and physical examination shows enlarged subcutaneous emphysema with loss of left lung breath sounds.
Examination of all equipment, except for hemodynamic management, revealed that the chest tube was disconnected from the suction device. Hemodynamic and respiratory conditions improve rapidly after re-aspiration and removal of the occlusive thrombus by irrigation. Intraoperative chest x-ray confirms correct positioning of the chest tube and shows that TPT has resolved.
Figure 1 View of AP immediately after surgery. The endotracheal tube is in place with the tip above the carina. The left chest tube has been aspirated and the tip protrudes correctly from the medial aspect of the left upper lung (red arrow). Medium-sized left-sided pneumothorax (white arrow) with some mass effect, mild rightward displacement, and widespread subcutaneous emphysema.
▲Figure 1 AP view, two hours after the initial chest x-ray, as shown in section A. Endotracheal tube placement remains unchanged. The left lung was intermittently dilated, and no obvious pneumothorax was seen. There is significant soft-tissue emphysema throughout the left hemithorax and at the thoracic entrance. Because the surgical team often performs chest drains, the anesthesiologist may assume that the chest tube is properly placed, functional, and that proper suction is being applied in preparation for awakening. When this assumption is wrong, life-threatening consequences can occur, as shown in this example. Anesthesiologists should maintain an awareness of chest tube management and be able to manage complications [2]. This knowledge enables anesthesia professionals to take the initiative, identify faults in drainage equipment, and ensure effective closed-loop communication between all OR team members. Chest drainage is a routine procedure that reexpands the lungs by draining fluid, blood, or air from the pleural space [3]. The chest tube is connected to the chest drainage system by a tee. Gravity or suction restores negative pressure in the pleural space by acting as a one-way valve to promote lung expansion. The collection chamber collects the discharged fluid, while in the water-sealed chamber, the water column prevents air from being drawn into the pleural space during inspiration. The suction chamber can be attached to a wall suction device or placed on a water seal (Figure 2). Whenever chest drainage is used, the tubing should be inspected for kinks, clamps, internal blockages (e.g., clots, fragments), and misalignment.
Fig.2 An example of a chest tube device commonly used in the operating room. Part A represents the dry suction control, which is preset to -20mm H2O but can be adjusted to any setting between -10 and -40mm H2O. Part B represents the water-sealed chamber. Part C is a water seal monitor that creates bubbles when there is an air leak. Part D is a collection chamber for collecting and measuring fluid from the patient. Part E is an inflatable orange bellows that is deflated without suction.
▲Figure 2B shows the chest tube device that has been suctioned. Note that the orange bellows outside the Part E triangle indicator expands, providing visual confirmation that suction is taking place (white circle).
In patients receiving mechanical ventilation, high pressure and air retention put patients at high risk of TPT if chest drainage does not work. Therefore, the chest tube device should be placed in a suction position when the chest cavity is closed to facilitate lung reexpansion, as postoperative pneumothorax is less likely to occur when aspiration is performed [4]. The presence of fluid oscillations in the water-sealed chamber (called "tides") directly reflects the degree of lung reexpansion, so the tides decrease with lung reexpansion. Prior to awakening, it is recommended that the anesthesiologist give verbal confirmation of the application of aspiration and visual confirmation by tide. It is important that all members of the operating room need multidisciplinary communication, shared responsibility, and vigilance to ensure proper chest tube management and prevent life-threatening complications.
Bibliography:
[1] Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical presentation of patients with tension pneumothorax: a systematic review. Ann Surg., 2015; 261: 1068-1078.
[2] Bacon AK, Paix AD, Williamson JA, Webb RK, Chapman MJ. Crisis management during anaesthesia: pneumothorax. Qual Saf Health Care. 2005; 14: e18.
[3] Porcel JM. Chest tube drainage of the pleural space: a concise review for pulmonologists. Tuberc Respir Dis (Seoul). 2018; 81: 106-115.
[4] Lang P, Manickavasagar M, Burdett C, Treasure T, Fiorentino F. Suction on chest drains following lung resection: evidence and practice are not aligned. Eur J Cardiothorac Surg. 2016; 49: 611-616.
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