Ann Thorac Surg 2006;82:1916
© 2006 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Bronchial Obstruction Causing Mediastinal Shift and Hemodynamic Compromise
Patrik Nechala, MD, FRCSC,
Alain Tremblay, MDCM, FRCPC,
Sean C. Grondin, MD, MPH*
Division of Thoracic Surgery, Department of Surgery, and Division of Pulmonary Medicine, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
* Address correspondence to Dr Grondin, Foothills Medical Centre, 1403 29th Street NW, Room G33D, Calgary, Alberta, T2N 2T9, Canada. (Email: sean.grondin{at}calgaryhealthregion.ca).
A 48-year-old man presented with dyspnea. He was diagnosed with a malignant obstruction of his right mainstem bronchus secondary to a nonsmall cell lung cancer originating from the right upper lobe. Due to the degree of dyspnea, rigid bronchoscopy was used to debulk the tumor and open the airway. Follow-up chest roentgenogram demonstrated good re-expansion of the right middle and lower lobes.
One month later, while undergoing staging, the patient again presented with dyspnea. On presentation his vital signs were within normal limits and oxygen saturation was 94% on 2 L of oxygen. Chest roentgenogram (Fig 1) demonstrated rightward mediastinal shift and extensive volume loss of the right lower and middle lobes (panel A). A diagnosis of recurrent malignant airway obstruction was made, and the patient was admitted for further treatment.
Four hours post-admission, the patient developed acute distress and became hemodynamically unstable with a heart rate of 110 bpm, blood pressure of 65/35, an elevated jugular venous pressure, and an oxygen saturation of 80% on a FIO2 of 1.0. After resuscitation and endotracheal tube placement, a chest roentgenogram demonstrated marked shift of the mediastinum to the right with near complete atelectasis of the right lung (panel B). A chest tube was inserted into the right hemithorax and was left open to the atmosphere to induce an open pneumothorax (panel C). Immediately after chest tube placement, the patient's vital signs normalized. The patient underwent rigid bronchoscopy, which confirmed the diagnosis of endobronchial tumor involving carina. The tumor was debulked and a stent was placed in the right main stem bronchus (panel D, arrow). The patient recovered uneventfully.
This case demonstrates the hemodynamic instability that can occur as a result of mediastinal shift toward the affected hemithorax secondary to malignant bronchial obstruction and resultant atelectasis.
