Intraoperative surprise evidence of bronchial rent during lung surgery: a case report.

Among multiple causes of tracheobronchial rent, most common is iatrogenic factor. Whenever there is surprise evidence of bronchial wall tear while doing lung surgery, tracheal tube extubation and postoperative management pose a challenge. We report a 16-year-old girl, weighing 27kg, a case of pulmonary Koch's who presented with hydropneumothorax on left side. She had a prolonged course on mechanical ventilation, was gradually weaned off and extubated in intensive care unit (ICU) with implantable cardioverter defibrillator (ICD) in-situ. However, chest X-ray continued to show loss of bronchovascular markings and high-resolution computed tomography (HRCT) thorax revealed multiple cavitatory lesions, hydropneumothorax from upper to lower lobe, ground glass opacities on left side and mediastinal shift towards right side. Hence, she was posted for left lung decortication. Decortication was done using one lung ventilation protocol with 28 Fr left sided double-lumen endobronchial tube (DLT). While checking for leaks before closure, it was noted that exhaled tidal volume was unacceptably low and a rent on left main bronchus of around 2x2 cm with scarred borders was detected. The rent was repaired with tissue patch suturing by the surgeons. After the procedure, DLT was exchanged with endotracheal tube (ETT) no 6. Patient was managed with elective ventilation post-operatively in ICU for 48 hours and extubated uneventfully. A vigilant monitoring of vital parameters and close communication with surgeons is important for detecting and managing any perioperative complication during lung surgery. Elective ventilation could play a significant role for healing a big rent in trachea-bronchial area.

A 34-Year-Old male admitted with pulmonary tuberculosis complicated by hydropneumothorax and mediastinal emphysema.

Spontaneous hydropneumothorax (HP) and mediastinal emphysema (ME) are infrequently presented complications of pulmonary tuberculosis (TB). A-34-year-old Pakistani male presented with dyspnea, productive cough, and right-sided pleuritic chest pain. He had no history of any surgery, TB, comorbid disease, or other serious pulmonary diseases. Chest radiography revealed a right-sided HP and parenchymal infiltration. The laboratory results of pleural effusion showed elevated adenosine deaminase levels with the empyema features. Acid-fast bacilli were detected and Mycobacterium tuberculosis without any drug resistance grew in the culture both in the sputum and pleural fluid. A chest tube was inserted immediately. A prolonged airway leak was detected. Hepatotoxicity protocol has been initialized (due to increased hepatic enzymes in the initial presentation) and followed without observing any complications associated with the treatment. On the 25th day of the standard TB treatment protocol, we observed hepatic enzymes in the normal range. Around 40-days of a hospitalization period, he started developing fever and methicillin-resistant Staphylococcus aureus was detected in the pleural fluid culture. We introduced linezolid to the treatment regimen in addition to the antituberculosis protocol. Although spontaneous ME is a benign disease, it might be life-threatening and difficult to manage when complicated with HP and active TB infection. Active TB should be considered a differential diagnosis once ME or HP was detected, and treatment should be started immediately for both diseases.

A Hydropneumothorax Captured by M-mode Ultrasonography

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Cerebral air embolism after indwelling pleural catheter insertion in a chronic hydropneumothorax secondary to epithelioid mesothelioma.

A 75-year-old man with a history of epithelioid mesothelioma and a right-sided indwelling pleural catheter (IPC) presented with a history of a purulent fluid drainage via the IPC. The pleural fluid cultured Klebsiella oxytoca and Enterococcus faecalis He was treated with a course of oral fluoroquinolone followed by uneventful IPC replacement. One and half hours postprocedure, the patient had a witnessed drop in conscious level accompanied by seizure like activity. Acute stroke was suspected and a CT head was performed. CT head revealed multiple serpiginous pockets of air along the cerebral fissure, with features that were highly suggestive of cerebral air embolism and multiple wedge-shaped areas of infarction involving the cerebral hemispheres. Further imaging revealed satisfactory position of the replaced IPC. The patient was admitted to the intensive care unit for high flow oxygen therapy and head down ventilation. However, his condition deteriorated and he died later.

Unusual case of retrosternal chest pain: a twist in the tale.

A 62-year-old man was referred to the emergency department with retrosternal chest pain for 4 days. Coronary angiogram and ECG showed no occlusion of coronary vessels. Contrast-enhanced CT of thorax showed b/l pleural effusion, pneumomediastinum, right hydropneumothorax, with the underlying collapse of lungs and intercostal drainage tube in situ. Intercostal tube showed purulent discharge. Repeat oral contrast did not show any leakage through the upper gastrointestinal tract, and the patient is admitted to the intensive care unit following endotracheal intubation. However, an upper gastrointestinal endoscopy, performed at the bedside in the intensive care unit unexpectedly revealed a foreign body (piece of coconut shell) impacted at the lower oesophagus. The foreign body was removed successfully using oesophagoscopy, and the patient made a full recovery following multidisciplinary teamwork between critical care and surgeons.