Kd. Stuhmeier et al., IPSILATERAL PNEUMOTHORAX DURING ONE-LUNG VENTILATION - A RARE, SUPPOSEDLY TYPICAL COMPLICATION IN THE USE OF DOUBLE-LUMEN TUBES, Anasthesist, 46(1), 1997, pp. 43-45
The authors report a rare, recently diagnosed and atypical mishap duri
ng one-lung ventilation (OLV) via a double lumen tube (DLT) and left-s
ided thoracotomy: an ipsilateral pneumothorax during ventilation of th
e right lung. This occurred in a 63-year-old patient with chronic obst
ructive airway disease who was scheduled for urgent repair of a descen
ding thoracic aortic aneurysm. Anaesthesia and surgery were uneventful
until aortic cross-clamping release. The common presentation of incre
ased intrathoracic extrapleural pressure owing to a pneumothorax in pa
tients with mechanically ventilated lungs is a rapid decrease in oxyge
n saturation, followed or paralleled by haemodynamic deterioration. Al
though the above presentation could be seen in this case, the diagnosi
s of a tension pneumothorax was delayed twice. First, symptoms were in
itially obscured by haemodynamic changes resulting from a head-down ti
lt and aortic declamping. Second, since the lack of consolidation afte
r aortic declamping focused attention on the airway problems, complica
tions resulting from the use of a DLT were primarily considered. In pa
rticular, since breathing sounds were detectable initially, malpositio
n or torsion of the DLT had to be excluded by fibre-optic bronchoscopy
, which involved a further delay. Finally, two observations led to the
diagnosis of a right-sided tension pneumothorax: (1) bullae of the co
ntralateral lung, detected during thoracotomy; (2) the finding that ve
ntilation of both lungs and the left lung subsequently increased arter
ial (SaO2) and mixed venous oxygen saturation (SvO2) and the circulato
ry status, but ventilation of the right lung caused a deterioration. C
hest radiography and insertion of a chest tube with drainage of air, t
hereafter, validated our hypothesis. The time course of oxygen desatur
ation during OLV and tension pneumothorax was as severe as expected; t
he time course of haemodynamic deterioration, however, appeared quicke
r and had more impact than expected. Assuming that mediastinal deviati
on was not hindered by contralateral intrathoracic pressure during tho
racotomy, we believed that circulation should be depressed later or to
a lesser extent in patients with an intraoperative pneumothorax. Yet,
during thoracotomy, decrease in cardiac filling and output during ten
sion pneumothorax in OLV obviously results primarily from the immovabi
lity of the mediastinum owing to mediastinal fixation and is at least
as decisive as the contralateral intrathoracic pressure in closed-ches
t patients. In summary, a tension pneumothorax during one-lung ventila
tion and thoracotomy is a rare, but disastrous complication during the
use of a DLT, which has not, to our knowledge, been reported previous
ly. We recommend that tension pneumothorax be added to the list of com
plications and problems during OLV by the use of a DLT, especially in
patients with structural lung diseases.