Tension Pneumothorax in the Operating Room: When Teamwork and Communication Save Patient Lives

Introduction

A tension pneumothorax (TPT) occurs when air accumulates in the intrapleural cavity, leading to lung collapse, pulmonary arterial shunting, hypoxemia, and hemodynamic collapse.¹ This case illustrates the importance of teamwork and communication, focusing on chest tube management, to promptly detect and treat a TPT.

Clinical presentation

A 60-year-old woman with active smoking, hypertension, AIDS, and hepatitis C presented with recurrent pneumonia with a loculated exudative pleural effusion. She underwent thoracentesis, pleural biopsy, chemical pleurodesis, and decortication via left thoracoscopy, complicated by parenchymal bleeding which required conversion to thoracotomy. While mechanically ventilated during repositioning from lateral to supine, sudden difficulties in ventilation and oxygenation were noted. High peak airway pressures, hypoxemia, tachycardia, and refractory hypotension developed, and physical exam revealed expanding subcutaneous emphysema with loss of left-sided lung sounds. In addition to hemodynamic management, a survey of all equipment identified suction disconnected from the chest tube apparatus. Application of suction and removal of occlusive thrombi via flushing resulted in rapid hemodynamic and respiratory improvements. Intraoperative chest x-ray confirmed proper chest tube positioning and revealed resolution of TPT (Figure 1).

Figure 1: Serial post-operative chest x-rays, demonstrating a tension pneumothorax and its resolution.

Discussion

Despite recent formalization of patient safety with mandated briefings and time-outs, the end of surgery is still a somewhat dysregulated time when mishaps can easily occur. Since the surgical team often manages the thoracostomy, an anesthesia provider may assume the chest tube is properly placed, functional, and has appropriate suction applied while preparing for emergence. When that assumption is erroneous, life-threatening consequences may occur, as in the presented case.

Anesthesia providers should maintain a working knowledge of chest tube management and its complications.² This knowledge empowers the anesthesia professional to take ownership, recognize malfunctioning of the drainage apparatus, and ensure effective closed-loop-communication among all operating room team members.

Chest tube thoracostomy is a routine procedure that drains fluid, blood or air from the pleural space, allowing lung re-expansion.³ Chest tubes are connected to chest drainage systems via a three-way chamber. Gravity or suction restores negative pressure to the pleural space by acting as a one-way valve to facilitate lung expansion. The collection chamber collects fluid drainage, while in the water seal chamber, a column of water prevents air from being drawn back into the pleural space during inhalation. A suction chamber may be connected to either wall suction or placed on a water seal (Figure 2).³ Whenever chest thoracostomy is used, the tubing should be inspected for kinks, clamps, internal blockages (e.g. clot, debris), and misplacement to ensure functionality (Table 1).²

Figure 2: Example of chest tube apparatus used in the operating room.

Table 1: Chest tube management safety checklist.

Chest Tube Apparatus

Position Unit is upright and below the level of the chest to maximize gravitational drainage Suction Suction source connected and turned on Bellows expanded, indicative of active suction Water seal chamber Water seal chamber filled properly with fluid (at least 2 cm H2O) Intermittent tidaling present Tidaling decreases as lung re-expands Continuous bubbling may be indicative of an air leak

Chest Tube Tubing

Inspect connecting tubing Ensure secure connection between thoracic catheter and drainage system Check tubing for cracks or defects, especially if an air leak persists despite clamping near patient Verify patent tubing by evaluating for blockages External blockages: remove kinks, loops, clamps (clamp OFF if suction ON) Internal blockages: flush tubing to remove potential debris or clot Examine insertion site Exposed distal tube eyelets indicate tubing may be outside of the pleural space Seal air leak at insertion site with occlusive dressing, if present

In mechanically ventilated patients, high pressures and air trapping place patients at high risk of TPT if the thoracostomy is not functioning. Therefore, the chest tube unit should be placed to suction upon chest closure to facilitate lung re-expansion, as development of post-operative pneumothorax is less likely when suction is applied.⁴ Presence of fluid oscillations in the water seal chamber (known as “tidaling”) is a direct reflection of the degree of lung re-expansion, such that tidaling decreases as the lung re-expands. Prior to emergence, an anesthesia provider’s verbal confirmation regarding application of suction as well as visual confirmation via tidaling are recommended. Importantly, multidisciplinary communication, shared responsibility, and heightened vigilance is required by all members of the operating room to ensure proper chest tube management and prevent life-threatening complications.

 

References

1. Roberts DJ, Leigh-Smith S, Faris PD, et al. Clinical presentation of patients with tension pneumothorax: a systematic review. Ann Surg., 2015; 261: 1068-1078.
2. Bacon AK, Paix AD, Williamson JA, Webb RK, Chapman MJ. Crisis management during anaesthesia: pneumothorax. Qual Saf Health Care. 2005;14: e18.
3. Porcel JM. Chest tube drainage of the pleural space: a concise review for pulmonologists. Tuberc Respir Dis (Seoul). 2018; 81: 106-115.
4. Lang P, Manickavasagar M, Burdett C, Treasure T, Fiorentino F. Suction on chest drains following lung resection: evidence and practice are not aligned. Eur J Cardiothorac Surg. 2016; 49: 611-616.