Richa Aggarwal

Pneumothorax following flexible fiberoptic bronchoscopy: A rare occurrence.

Sir, Pneumothorax following flexible fibreoptic bronhoscopy is rare. It occurs 1 in 450 bronchoscopy.[1] We report a case of such event in a trauma victim. A 34-year-old male patient with alleged history of road traffic accident admitted in our trauma center. On initial examination, his airway was patent, he was breathing at the rate of 22 breaths/min with air entry diminished over the right lung. Initial hemodynamics were stable with heart rate of 96 beats/min and blood pressure of 126/88 mmHg. Contrast-enhanced computed tomography scan chest revealed the fracture of 1st, 2nd, 3rd, and 7th ribs on the right side with hemopneumothorax and multifocal contusions in all lobes of the right lung. A right-sided intercostal tube drain (ICD) was placed. Pneumothorax and hemothorax resolved subsequently. He was shifted to the general ward. After 4 days of admission, patient developed acute respiratory distress with fall in oxygen saturation (90%) and was transferred to trauma intensive care unit (ICU). On initial evaluation, his chest X-ray showed [Figure 1] right lung collapsed with mediastinal shift toward the right side. A flexible bronchoscopy was contemplated in view of provisional diagnosis of mucus plug obstructing the major airways. A flexible bronchoscopy was carried out and a large mucus plug was aspirated from the right bronchus thereby clearing the airway. The patient was kept on positive pressure ventilation after the procedure. Immediately following the flexible bronchoscopy a large air leak became apparent in right-sided ICD. A follow-up chest X-ray showed a new large pneumothorax and collapse whole lung [Figure 2]. Ventilatory settings were adjusted to minimize the leak and the ICD was connected to negative pressure of 15 mmHg. A second ICD was inserted in order to control the leak and expand the lung. After 2 days, air leak controlled and lung got expanded. Patient was shifted to high dependency unit for further care. Figure 1 Chest X-ray showed collapsed right lung with mediastinal shift toward the right side Figure 2 Chest X-ray demonstrated a new large pneumothorax and collapse of whole the right lung Flexible fiberoptic bronchoscopy is a safe procedure carried out in patients admitted to ICUs. Its indication varies between diagnostic to therapeutic interventions including regular bronchoalveolar lavage for microbiological sampling, diagnosis of pulmonary hemorrhage, use in cases of difficult intubation, as a control in percutaneous tracheostomies, and aspirations of secretions.[2] Its use in clearing the airway because of mucus plug is considered as a standard practice particularly in patients where physiotherapy has failed to do so. However, its complications are infrequent. Most frequent complications cited in the literature are supraventricular tachycardia (3.8%), transient hypoxemia (6.7%), and slight bleeding of the bronchial mucosal membrane (2.4%).[2] Pneumothorax following flexible bronchoscopy has been reported infrequently in literature. Pue et al. have reported pneumothorax following flexible bronchoscopy in 0.16% of cases. Predominantly, it followed transbronchial biopsy procedure.[3] de Blic et al. analyzed prospectively in 1328 flexible bronchoscopy procedures in children and noted 0.1% incidence of pneumothorax.[4] In both the above analysis, none has reported pneumothorax following aspiration of secretion or mucus plug in case of chest injury following trauma. Moreover, flexible fiberoptic bronchoscopy was used here as a diagnostic modality to identify the cause of persistent pneumothorax and bronchial injuries. Mechanism that might have led to pneumothorax in our patient can be attributed to initial lung injury. Probably, the mucus plug had sealed the existent bronchial rent underlying lacerated lung and corrected the initial hemopneumothorax. As soon as the mucus plug got aspirated during flexible bronchoscopy the lung laceration got expose to high airway pressures and caused escaping of air into the pleural cavity. To conclude, although flexible bronchoscopy is a safe procedure, it mandates close monitoring during and after the procedure. It is important to have a high index of suspicion and a follow-up chest X-ray to identify a potentially dangerous complication.

Ultrasound and fibreoptic-guided percutaneous tracheostomy in patient with deviated trachea

Anaesthesiology Intensive Therapy 2016, vol. 48, no 2, 148–149 ISSN 0209–1712 10.5603/AIT.2016.0025 www.ait.viamedica.pl 8. Kareem E, Riem H, Firas S: Inflammatory bowel disease-related thoracic Aortic Thrombosis. South Med J 2010; 103: 172−174. doi: 10.1097/ SMJ.0b013e3181c95bc8. 9. Miechsler NP, Lator P, Valic E et al.: Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism? Gut 2004; 53: 542−548. Corresponding author: Małgorzata Malec-Milewska MD, PhD Department of Anaesthesiology and Intensive Care Medicine, Medical Centre for Postgraduate Education, Ul. Czerniakowska 231, 00−416 Warsaw, Poland e-mail: lmilewski@post.home.pl

Challenges in management of pediatric life-threatening neck and chest trauma

Introduction: Neck and thoracic trauma in children pose unforeseen challenges requiring variable management strategies. Here, we describe some unusual cases. Patients and Methods: Pediatric cases of unusual neck and thoracic trauma prospectively managed from April 2012 to March 2014 at a Level 1 trauma center were studied for management strategies, outcome, and follow-up. Results: Six children with a median age of 5.5 (range 2–10) years were managed. Mechanism of injury was road traffic accident, fall from height and other accidental injury in 2, 3 and 1 patient respectively. The presentation was respiratory distress and quadriplegia, exposed heart, penetrating injury in neck, dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases respectively. Injuries included lung laceration, open chest wall, vascular injury of the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis. One patient had a flare of miliary tuberculosis. Immediate management included chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal stapling, and feeding jejunostomy (followed by gastric pull-up 8 months later). Chest tube insertion and total parenteral nutrition was required in one each. 2 and 4 patients required tracheostomy and mechanical ventilation. The patient with gastric pull-up developed a stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. At follow-up of 40–61 months, five patients are well. One patient with penetrating neck injury suffered from blindness due to massive hemorrhage from the vascular injury in the neck and brain ischemia with only peripheral vision recovery. Conclusion: Successful management of neck and chest wall trauma requires timely appropriate decisions with a team effort.

Outcome of patients of chest trauma suffering from chronic obstructive pulmonary disease — experience at level 1 trauma centre

BACKGROUND The outcome of chest trauma depends on many factors, one of which includes comorbidities. Nowadays, as the elderly population is on the rise, more and more trauma victims are being admitted with chronic obstructive pulmonary disease as a comorbidity in trauma centre intensive care units. However, there are hardly any studies describing the outcome of such patients with chest trauma and chronic obstructive pulmonary disease, both being respiratory problems. The aim was to study the outcomes and various complications in patients of chest trauma with COPD admitted to our ICU over a given time period. METHODS A detailed review of charts of patients with chest trauma and chronic obstructive pulmonary disease admitted over one and a half years was performed and various parameters noted, including as follows: demographic data; various scores; the number of days on a ventilator and in the ICU. Moreover, complications, such as ventilator associated pneumonia, catheter related bloodstream infections, as well as outcomes, were noted. RESULT During the study period, 19 patients were admitted, out of which 4 died. The APACHE scores were higher for those who died and all had ventilator-associated pneumonia as a complication. All those who had undergone the placement of an epidural and were managed with non-invasive ventilation initially did not require invasive ventilation. CONCLUSIONS Chest trauma patients with chronic obstructive pulmonary disease are prone to develop ventilator-associated pneumonia which may be the source of increased mortality among such patients. Epidural placement reduces the risk of invasive ventilation if a patient can be managed with non-invasive ventilation.

Should intensivist do routine abdominal ultrasound

Roundworm infestation is common in tropical climate population with a low socioeconomic status. We describe a case of a young male with polytrauma accident who presented with small bowel dysfunction with a high gastric residual volume during enteral feeding. While searching the etiology, the intensivist performed bedside abdominal ultrasound (USG) as a part of whole body USG screening along with clinical examination using different frequency probes to examine bowel movement and ultimately found ascariasis to be the cause. This case report will boost up the wide use of bedside USG by critical care physicians in their patient workup.

Delayed massive hydrothorax following subclavian catheter insertion: an unusual complication.

Complications of central venous catheter can become life threatening if not managed timely. We present a case of massive hydrothorax that developed few hours after placement of the central venous pressure line. The diagnosis was little delayed because the catheter was normally placed initially and later got displaced within few hours of shifting to the intensive care unit. However, the patient was managed timely. Our case report suggests that the position of the catheter should be checked frequently in the intensive care unit and particularly so after shifting and positioning of the patient and the associated complications should be kept in mind.

Intensive care unit management of a posttraumatic pneumonectomy case

Sir, Tracheobronchial rupture following blunt chest trauma is rare and life-threatening. Surgical repair is done in most cases and pneumonectomy is avoided whenever possible as emergency pneumonectomy carries high mortality rate of 50-70%.[1] This is due to contributory effects of hypotension, hypoxia and abrupt rise in pulmonary vascular resistance leading to right ventricular failure[2] and so postoperative care in intensive care unit (ICU) is very important. We describe ICU management of such a case. An 18-year-old male of chest trauma presented to the emergency referred from another hospital. Vitals were pulse 113/min, blood pressure 152/82 mmHg, respiratory rate (RR) 35/min, saturation 84% with massive subcutaneous emphysema and intercostal chest drain (ICD) in situ. Patient was immediately intubated, and another ICD inserted on the right side. Chest X-ray (CXR) post ICD revealed massive pneumothorax on right side [Figure 1]. Computed tomography chest revealed complete transection of right main bronchus. Patient was shifted to emergency operation theatre and intubated with double lumen tube (DLT). Intraoperatively as bronchial anastomosis was not possible, right sided pneumonectomy was done, and patient was shifted to the ICU. In the ICU, instead of changing to a single lumen tube, we ventilated the patient with DLT [Figure 2] only for 12 h as there were high chances of bronchial stump rupture. Patient was kept on volume control with a tidal volume 5 ml/kg, positive end expiratory pressure (PEEP) of 5 cm H2O, with respiratory rate (RR) adjusted to limit plateau airway pressure to 20 cm H2O. PaCO250-55 mmHg was accepted. Fluid intake was restricted to maintain urine output >0.5 ml/kg/h. Weaning was started after 24 h and patient extubated on the 3rd postoperative day and put on noninvasive ventilation (NIV) intermittently for the next 2 days. CXR was done daily to monitor the fluid in postpneumonectomy space (PPS). With active physiotherapy and mobilization, patient did well and was discharged from ICU on 9th postoperative day [CXR, Figure 3] and from the hospital on 14th day. At the time of discharge, he could climb two flights of stairs without dyspnea. Figure 1 Preoperative chest X-ray of patient showing collapsed lung with intercostal chest drain in situ Figure 2 Postoperative chest X-ray showing left sided double lumen endotracheal tube Figure 3 Chest X-ray on 8th postoperative day showing postpneumonectomy space filled with fluid The common causes of early postoperative death after emergency pneumonectomy are bleeding, postpneumonectomy pulmonary edema, right ventricular failure and arrhythmias,[2] risk factors being increased age, higher injury severity score, right sided pneumonectomy and comorbid condition.[3] The incidence of pulmonary edema is higher for right pneumonectomy but can be avoided with judicious fluid management. We maintained a negative fluid balance of 500 ml/24 h. Radiographic monitoring of PPS is crucial. Immediately after surgery PPS fills with air.[4] Then, fluid accumulates at a rate of two rib spaces per day and 80-90% is filled in 2 weeks. If fluid accumulates more rapidly, then possibility of hemorrhage, infection or chylothorax should be kept in mind. Arrythmias are seen in 9-34% patients, mainly in advanced age group.[5] After pneumonectomy work of breathing increases so patient remains tachypenic. We kept our patient on NIV intermittently and accepted an RR of 25-30/min. In conclusion, adequate knowledge about changes postpneumonectomy and management of complications are vital for a favorable outcome.

Is abdomen release really necessary for prone ventilation in acute respiratory distress syndrome

Prone ventilation for refractory acute respiratory distress syndrome (ARDS) mandates free abdomen by rolls in between chest wall and pelvic bones for better ventilation and control of airway pressure. We observed that, in patients with severe ARDS, prone ventilation with movable free abdomen produced high plateau pressure reduced by applying simple support to abdominal wall. Here, we have proposed a possible hypothesis to explain the paradoxical event in this particular group of patients. The increased alveolar volume in prone position is counteracted by reduction in rib cage diameter caused by weight of abdomen. In patients with severe ARDS in prone position, gravitational pressure transmits through abdominal support, resulting in better chest wall expansion and leading to more oxygenation and opening of the alveoli in ventral lung along with the dorsal lung portion that is usually better ventilated in prone position. There is no clinical trial regarding this particular observation. We suggest randomized trials to prove our observational findings.