Ann Thorac Surg 2006;81:1482-1484
© 2006 The Society of Thoracic Surgeons
Case report
Management of Multiple Tension Pneumatoceles Refractory to Tube Thoracostomy Decompression
En-Ting Wu, MD
a
,
Jin-Shing Chen, MD, PhD
b
,
*
a Department of Pediatrics, National Taiwan University Hospital Taipei, Taiwan
b Department of Surgery, National Taiwan University College of Medicine, Taipei, Taiwan
Accepted for publication May 9, 2005.
* Address correspondence to Dr Chen, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, Taiwan (Email: cjs{at}ha.mc.ntu.edu.tw).
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Abstract
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A 10-month-old boy had multiple tension pneumatoceles develop 4 weeks after pneumonia with parapneumonic empyema caused by methicillin-resistant Staphylococcus aureus. The pneumatoceles failed to completely respond to tube thoracostomy drainage, and sudden onset of cardiopulmonary collapse occurred after induction of anesthesia. He was rescued by multiple percutaneous venous catheter decompressions, followed by lobectomy. Our experience showed that surgery remains the definitive treatment for pediatric patients with multiple tension pneumatoceles. However, extra caution should be taken in the preoperative management of these patients, even in the presence of tube thoracostomy.
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Introduction
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In pediatric patients, pneumatoceles usually developed after pneumonia. Although most pneumatoceles regress with the underlying disease process, tension pneumatoceles may occasionally occur and cause cardiopulmonary instability. For patients with a single tension pneumatocele, an image-guided percutaneous decompression using tube thoracostomy or catheter drainage is an effective treatment and may avoid subsequent surgical intervention. However, multiple tension pneumatoceles are extremely rare and the optimal management remains to be defined.
A previously healthy 10-month-old boy experienced high fever and tachypnea for 3 days. Upon admission, the chest roentgenogram revealed consolidation of the left lung with parapneumonic effusions. He was intubated for ventilator support due to hypoxemia on the following day. High fever up to 40°C persisted and a computed tomographic scan of the chest revealed necrotizing pneumonia of the left lower lung lobe with massive parapneumonic empyema. Sputum cultures yielded methicillin-resistant Staphylococcus aureus. Video-assisted thoracoscopic surgery was performed on the fifth day of admission for debridement of the parapneumonic empyema. Fever subsided gradually, and extubation was done 3 days later. After vancomycin treatment, the boy was discharged on day 21. The follow-up chest roentgenogram showed complete resolution of the pneumonia, but many small pneumatoceles were noted at the lower field of the left lung (Fig 1A).
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Fig 1. (A) Chest roentgenogram 25 days after video-assisted thoracoscopic surgical (VATS) debridement of parapneumonic empyema showed multiple pneumatoceles located in the left lower lung field. (B) Chest roentgenogram 30 days after VATS showed a huge pneumatocele and several small ones in the left lung with right-deviated mediastinum. (C) Computed tomographic scan showed multiple variably sized pneumatoceles occupying the left chest with compression of the heart and the remaining left lung. (D) After tube thoracostomy, the follow-up chest roentgenogram showed partial resolution of the pneumatoceles and incomplete returning of the position of the mediastinum.
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However the patient had a sudden onset of tachypnea develop 30 days after the first admission. Chest roentgenogram showed multiple, variably-sized, air-filled cystic lesions occupying the left hemithorax. The heart was pushed toward the right side (Fig 1B). The patient was admitted to the intensive care unit with the following vital signs: blood pressure of 58/43 mm Hg, pulse rate of 180 beats/minute, respiratory rate of 70 breaths/min, temperature at 37°C, and oxygen saturation of 95% at 50% of fraction of inspired oxygen. Physical examination revealed distended jugular veins, diminished left-sided breath sounds, and right-deviated heart sounds. Computed tomographic scan of the chest showed multiple pneumatoceles occupying the whole left pleural cavity with the largest one being greater than 10 cm in diameter. The mediastinum was deviated to the right side, and the remaining left lung was severely compressed (Fig 1C). Tube thoracostomy was emergently performed under the guidance of computed tomographic scan to decompress the largest pneumatocele. Vital signs were improved after placement of the chest tube, but the follow-up chest roentgenogram did not show complete normalization of the position of the mediastinum (Fig 1D). Unfortunately the patient had dyspnea develop again 2 days later with progressive subcutaneous emphysema. The remaining undrained pneumatoceles enlarged as compared with the previous chest roentgenogram. The baby was taken to the operating room for definitive resection of the multiple tension pneumatoceles. With the induction of anesthesia and the initiation of positive pressure ventilation, a sudden collapse of his vital signs ensued, and he was resuscitated by blind percutaneous needle decompression using three 14-gauge venous catheters at the subclavian area of the second intercostal space and anterior and posterior axillary lines of the fifth rib, respectively. The cardiopulmonary function resumed stable after gushing out the retained air. Through a left-sided thoracotomy, the pneumoatoceles were opened by electrocautery. A left lower lobectomy of the lung was performed, because all the lesions originated from the lobe. The boy had an uneventful recovery and was discharged 7 days later. The follow-up chest roentgenogram showed full expansion of the left upper lung lobe and there is no evidence of any residual pneumatocele.
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Comment
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Pneumatoceles are air-filled, thin-walled lung cysts that occur after injury or inflammation of lung parenchyma. In the pediatric group, pneumatoceles are recognized as a complication of pneumonia with various pathogens [1], among which S. aureus is the most commonly mentioned [2]. Post-infectious pneumatoceles usually appear within the first week of pneumonia and regress with the underlying disease process in an average of 6 weeks [2]. Occasionally, pneumatoceles may induce complications such as tension formation and secondary infection. Tension pneumatocele is usually associated with mechanical ventilation and necessitates emergent decompression due to compromise of cardiopulmonary function [3]. For patients with a single tension pneumatoceles, percutaneous drainage by needle aspiration, tube thoracostomy, [4] or catheter drainage [5] under the guidance of fluoroscope or computed tomographic scan has been reported as a quick, safe, and effective treatment, making surgical pneumonostomy with subsequent lung resection rarely indicated [6].
Multiple tension pneumatoceles in the pediatric patient is extremely rare, and the optimal management is not known. In this patient, multiple pneumatoceles were noted 4 weeks after methicillin-resistant S. aureus pneumonia and were followed by an abrupt onset of tension formation under spontaneous breathing. The multiple tension pneumatoceles are refractory to tube thoracostomy decompression, because only one or two pneumatoceles can be decompressed. Therefore surgical intervention is indicated to completely decompress the tension and prevent a later recurrence. However, from the experience of this patient, precaution should be taken in the preoperative anesthesia, because the remaining undrained pneumatoceles could enlarge abruptly after intubation and positive pressure ventilation, which may then induce cardiopulmonary instability.
To prevent exacerbation of tension formation, a previous report suggests that high-frequency oscillatory ventilation could be applicable [7]. However, the device is usually not available in the operation room. Single lung ventilation by double lumen endotracheal tube or a bronchial blocker is also an alternative way to prevent tension formation during the anesthesia or operation. In our patient, a double lumen endotracheal tube is not suitable because of the small tracheal size in this baby. Placement of a bronchial blocker at the left main bronchus to prevent air entry into the distended pneumotoceles should be considered, although it was not tried in our patient because of technical demands. Once tension formation occurred, our experience demonstrated that blind multiple percutaneous needle decompression using venous catheters provides a quick, simple, and life-saving alternative. We do not suggest additional tube thoracostomy or image-guided catheter drainages, because they are time consuming in view of the urgent state.
In summary, our experience indicates that pediatric patients with post-infectious multiple pneumatoceles should be informed about the possibility of abrupt tension formations. Image-guided decompression using catheters or chest tubes is indicated to relieve the acute symptoms. Thoracotomy remains the definitive treatment for resection of the diseased lung and prevention of later recurrence. However, tension formation may recur and complicate the preoperative course, even in the presence of tube thoracostomy. Single lung ventilation may be considered in this situation. If failed or not feasible, multiple, blind, percutaneous venous catheter decompression provides an easy and effective procedure to rescue the emergent situation.
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References
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Abstract
Introduction
