Abstract
Purpose: We describe an unusual presentation of a case of fulminant unilateral pulmonary edema caused by unrecognized right endobronchial intubation that occurred during patient movement at the end of surgery. We review factors which may predispose to this complication.
Clinical features: During emergence from anesthesia at the conclusion of bariatric surgery, a 27-yr-old patient (163 kg, body mass index 61.5 kg·m−2) became hypoxemic despite vigorous spontaneous ventilatory efforts through a 7.0 mm endotracheal tube with 100% oxygen. Right mainstem endobronchial tube malposition was detected by auscultation. The tube was re-positioned, followed by copious pink frothy pulmonary edema abruptly issuing from the tracheal tube. Chest radiography revealed dense left lung infiltrates, consistent with unilateral negative pressure pulmonary edema, caused by brief, but forceful, inspiratory efforts against an obstructed left bronchus. This condition resolved over the following 24 hr. The patient’s trachea was then extubated, and the remainder of her recovery was unremarkable.
Conclusions: A high degree of airway anatomic variation, common tracheal tube insertion practices, unreliability of tube position detection methods, and the effects of patient positioning may all contribute to endotracheal tube malposition, including partial endobronchial intubation. Several modifications in airway management may help to prevent such complications of tracheal tube malposition.
Résumé
Objectif: Nous décrivons la présentation inhabituelle d’un cas d’µdème pulmonaire unilatéral fulminant provoqué par une intubation endobronchique droite non détectée, survenue pendant le déplacement du patient à la fin de la procédure chirurgicale. Nous passons en revue les facteurs susceptibles de prédisposer à cette complication.
Éléments cliniques: Pendant l’émergence de l’anesthésie après une chirurgie de l’obésité, un patient âgé de 27 ans (163 kg, indice de masse corporelle 61,5 kg·m−2) est devenu hypoxémique malgré des efforts soutenus de ventilation spontanée via un tube endo-trachéal de 7,0 mm avec de l’oxygène 100 %. Le positionnement inadéquat du tube dans la bronche souche droite a été détectée par auscultation. Le tube a été repositionné, mais suivi de l’irruption d’un œdème pulmonaire abondant spumeux et rose provenant de la sonde trachéale. La radiographie des poumons a révélé d’épais infiltrats dans le poumon gauche, compatibles avec un µdème pulmonaire par pression négative unilatérale et provoqué par des efforts inspiratoires brefs mais soutenus pour dégager une bronche gauche obstruée.
Conclusion: Une importante variation anatomique des voies respiratoires, les pratiques usuelles d’insertion de la sonde trachéale, le manque de fiabilité des méthodes de détection de la position du tube et les conséquences du positionnement du patient peuvent tous jouer un rôle et provoquer un positionnement inadéquat du tube endotrachéal, y compris une intubation endobronchique partielle. Plusieurs modifications dans la prise en charge des voies aériennes pourrait nous aider à éviter de telles complications à la suite du mauvais positionnement du tube endotrachéal.
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This work was supported entirely by departmental funds. The authors have no conficts of interest pursuant to this report.
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Goodman, B.T., Richardson, M.G. Case report: Unilateral negative pressure pulmonary edema — a complication of endobronchial intubation. Can J Anaesth 55, 691–695 (2008). https://doi.org/10.1007/BF03017745
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DOI: https://doi.org/10.1007/BF03017745