Abstract
Purpose: To illustrate a new airway and ventilatory management strategy for patients with unilateral penetrating lung injury. Emphasis is placed on avoiding positive pressure ventilation (PPV)-induced systemic air/gas embolism (SAE) through traumatic bronchiole-pulmonary venous fistulas.
Clinical Features: A 14-yr-old male, stabbed in the left chest, presented with hypovolemia, left hemopneumothorax, an equivocal acute abdomen, and no cardiac or neurological injury. In view of the risk of SAE, we did not ventilate the left lung until any fistulas, if present, had been excised. After pre-oxygenation, general anesthesia was induced and a left-sided double-lumen tube (DLT) was placed to allow right-lung ventilation. Bronchoscopy was performed. The surgeons performed a thorascopic wedge resection of the lacerated lingula. Upon completion of the repair, two-lung ventilation was instituted while the ECG, pulse oximetry, PETCO2, and blood pressure were monitored. Peak inflation pressure was increased slowly and was well tolerated up to 50 cm H2O. The patient’s intravascular status was maintained normal.
Conclusion: Patients with lung trauma are at risk of developing SAE when their lungs are ventilated with PPV. In a unilateral case, expectant non-ventilation of the injured lung until after repair is recommended.
Résumé
Objectif: Illustrer une nouvelle façon de protéger les voies aériennes et d’assurer la ventilation chez des patients victimes de lésions pulmonaires unilatérales par pénétration. On veut surtout éviter l’aéroembolie ou l’embolie gazeusesystémique (AES) induite par la ventilation à pression positive (VPP) au travers de fistules brochioliques et veineuses pulmonaires.
Éléments cliniques: Un garçon de 14 ans, poignardé au côté gauche, présentait une hypovolémie, un hémopneumothorax gache, un abdomen aigu possible, mais aucune lésion cardiaque ou neurologique. Étant donné le risque d’AES, la ventilation du poumon gauche a été retardée jusqu’à ce que toute fistule possible ait été excisée. Après une pré-oxygénation, l’anesthésie générale a été induite et un tube à double lumière gauche (TDL) a été inséré pour permettre la ventilation du poumon droit. On a procédé à une brochoscopie. Les chirurgiens ont réalisé une résection cunéiforme thoracoscopique de la lingula lacérée. Une fois la réparation terminée, la ventilation bipulmonaire a été instaurée tandis que l’ECG, l’oxymétrie pulsée, la PETCO2 et la tension artérielle étaient placés sous monitorage. La pression de distension maximale a été augmentée lentement et a été bien tolérée jusqu’à 50 cm H2O. L’état intravasculaire a été maintenu normal.
Conclusion: Les patients victimes de truamatisme pulmonaire sont à risque de subir une AES lorsque leurs poumons sont ventilés sous une VPP. Dans le cas d’un traumatisme unilatéral, il est recommandé de ne pas utiliser la ventilation du poumon lésé avant la fin de la réparation.
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Ho, A.M.H., Lee, S., Tay, B.A. et al. Lung isolation for the prevention of air embolism in penetrating lung trauma. A case report. Can J Anesth 47, 1256–1258 (2000). https://doi.org/10.1007/BF03019878
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DOI: https://doi.org/10.1007/BF03019878