Background: Cardiac herniation is a serious postoperative complication of extrapleural pneumonectomy (EPP) and is reportedly preventable by reducing the suction pressure of the chest drain. Case presentation: We describe a patient in whom respiratory failure, which was caused by impending tension pneumothorax after EPP, was successfully treated via normal suction pressure of the chest drain. A lower suction pressure (−7cmH O) was chosen as an alternative to the setting typically used for postoperative drainage (− 15 cmH O).As a result,the woundinthe chestwallfunctionedas anantireflux check valve, leading to the development of impending tension pneumothorax. Conclusions: Impending tension pneumothorax presents with an abnormal elevation of intrapleural pressure on the affected side. This phenomenon can be effectively treated by increasing the suction pressure in the chest drain. Keywords: Extrapleural pneumonectomy, Pneumothorax, Respiratory failure, Cardiac herniation Background Case presentation Extrapleural pneumonectomy (EPP) is a surgical proced- A 33-year-old man (height, 176 cm; weight, 71 kg) vis- ure involving en bloc resection of the affected lung and a ited our hospital with a chief complaint of respiratory part of the diaphragm and pericardium. Because of its discomfort. The patient reported a history of smoking high invasiveness, several complications have been re- (20 cigarettes per day) between 20 and 31 years of age; ported in association with the procedure. Major complica- otherwise, his medical and family histories were unre- tions of EPP include atrial fibrillation and other forms of markable. Computed tomography detected pleural effu- arrhythmia, as well as heart failure caused by increased sion and an anterior mediastinal tumor. A detailed right ventricular strain related to the absence of one lung examination led to the diagnosis of thymoma (stage IVb: [1–3]. Complications requiring surgery have been re- pleural dissemination involving the superior vena cava ported, including cardiac herniation, cardiac tamponade, [SVC] and brachiocephalic vein). The patient exhibited a bronchopleural fistula, and diaphragmatic hernia . The partial response to radiation therapy and chemotherapy; present report describes our experience with a patient thus, the implementation of right EPP and partial who developed impending tension pneumothorax on the replacement of the SVC were scheduled with the aim of affected side after EPP, followed by hypercarbia associated achieving cytoreduction by removing as much of the with compression of the unaffected lung. thymoma as possible. Preoperative respiratory function test results were as follows: vital capacity (VC), 5.51 L; %VC, 113.6%; forced expiratory volume in 1 s (FEV ), 4.6 L; and FEV 1.0%, 85.5%. Blood gas testing revealed a pH of 7.422; partial * Correspondence: email@example.com pressure of carbon dioxide (PaCO ), 40 mmHg; partial Department of Anesthesiology and Pain Clinic, Juntendo University pressure of oxygen (PaO ), 96.9 mmHg; and bicarbonate Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka 410-2295, Japan (HCO ), 25.6 mmol/L. No abnormalities were observed Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Sakuraba et al. JA Clinical Reports (2018) 4:45 Page 2 of 4 in preoperative cardiac function. Chest radiography re- pectoral muscle. The patient exhibited normal breath vealed a mediastinal tumor shadow, but no abnormalities sounds in the left lung. Further, there was no air leak were detected in the lung fields. from the chest tube without kinks, clogs, or regurgitation On arrival to the operating room, the epidural catheter during inspiration of the chest tube system. The measure- was inserted at the level of thoracic vertebrae 7/8 ments of arterial blood gases were 7.207 for pH, 68 mmHg successfully. General anesthesia was induced by using for PaO , and 64 mmHg for PaCO ; accordingly, the con- 2 2 remifentanil (1.0 μg/kg/min), rocuronium (40 mg), and dition was diagnosed as hypoventilation-associated hypox- propofol (target-controlled infusion [TCI], 3.0 μg/mL). emia/hypercapnia. Hypercapnea cannot be explained by The airway was secured using a 37-Fr left-sided double intraoperative opioid use because we did not include lumen tube (Smiths Medical, Minneapolis, MN, USA), opioids for postoperative continuous epidural analgesia. In which was inserted at a point above the bifurcation of terms of hemodynamics, the patient’s blood pressure was the trachea via a bronchoscope. Anesthesia was main- elevated, and his heart rate had increased. There were no tained using propofol (TCI 3.0 μg/mL) and remifentanil signs of strider or wheeze; additionally, the patient did not (0.4–0.8 μg/kg/min), under 40–100% oxygen. Monitor- complain of pain, was able to breathe deeply as instructed, ing tools included a five-lead ECG system, pulse oxim- and exhibited clear consciousness. To improve oxygen- eter, and expired gas monitor. Bispectral index (BIS™, ation, the use of a bi-level positive airway pressure mask Medtronic PLC, Dublin, Ireland) was used to monitor was initiated; however, the patient’s respiratory discomfort the depth of anesthesia. Hemodynamic monitoring was remained and his pulse oximetry reading only minimally performed via direct measurement of arterial pressure improved (to 92%). Chest radiography revealed a medias- and measurement of central venous pressure. The chest tinal shift, which was suspected to have arisen due to lining was cut, the right phrenic nerve was separated, impending tension pneumothorax associated with mal- and the right diaphragm was removed. The left brachio- function of the chest drain (Fig. 1). Thus, suction pressure cephalic vein was bypassed to the right atrial appendage, of the chest drain was increased from −7to − 15 cmH O, and the right brachiocephalic vein was bypassed to the which immediately improved respiratory discomfort. SVC. The portion of the SVC with suspected residual Chest radiography also revealed improvement of the tumor was dissected. After the lung hilum was treated, mediastinal shift and adequate dilation of the left lung both the tumor and the right lung were removed; some in- (Fig. 2). jury to the trachea was repaired. The right diaphragm and pericardium were reconstructed using a GORE-TEX® sheet (W.L. Gore and Associates, Newark, NJ, USA). The procedure was performed while visually observing the left lung. As the anterior junction line was maintained, a left-sided chest drain was not inserted. The initial dose of 0.2% ropivacaine (5 mL) was injected into the epidural space when the chest incision was closed. Then, a con- tinuous infusion of 0.2% ropivacaine (5 mL/h) without narcotics was initiated for postoperative analgesia. No ab- normalities were observed in terms of intraoperative ECG and hemodynamics. The duration of anesthesia was 10 h and 12 min; the operative time was 8 h and 5 min. The infusion volume was 3550 mL, blood loss volume was 1540 g, and urine volume was 2120 mL. Following surgery, bronchoscopic observation of the trachea under anesthesia revealed minimal phlegm. After the patient awoke from anesthesia and began to breathe spontaneously, his pulse oximetry reading was main- tained at 100% and he did not complain of postoperative wound pain; thus, the patient was extubated. However, immediately after extubation, labored respiration began and breathing rate markedly increased. Pulse oximetry decreased to 84% under the administration of 6 L/min Fig. 1 Chest radiograph before the elevation of the chest drain’s of oxygen via face mask. There was little sputum or suction pressure from 7 to 15 cmH O. This reveals mediastinal shift hemosputum, but subcutaneous emphysema was evident that may have been attributable to tension pneumothorax in the right subcutaneous area and streak of the large Sakuraba et al. JA Clinical Reports (2018) 4:45 Page 3 of 4 it may lead to serious conditions, including reduced blood pressure and obstructive shock [5–7]. In cases with tension pneumothorax, an open chest wound or an injury site in the lung exhibits a one-way valve mechan- ism because it allows air to enter the pleural cavity dur- ing inspiration but closes during expiration, thereby leading to the progressive accumulation of air in the pleural cavity. When these conditions persist, the intra- pleural pressure on the affected side gradually increases, resulting in the development of tension pneumothorax. If not detected promptly, the condition may trigger cardiac arrest [5, 6]. In general, tension pneumothorax is often worsened by positive pressure ventilation [5, 6]. In the present case, no apparent air leakage was recognized during positive pressure ventilation, indicating no bronchopleural air leakage. Thus, the patient’srespiratory status did not worsen during positive pressure ventilation. However, as spontaneous respiration increased, intra- pleural pressure became a strong negative pressure that surpassed the chest drain suction pressure of −7cmH O. Additionally, the wound in the chest wall functioned as an antireflux check valve, leading to the development of impending tension pneumothorax [5, 6]. Cardiac hernia- Fig. 2 Chest radiograph after the elevation of the chest drain’s tion is a serious postoperative complication of EPP and is suction pressure from 7 to 15 cmH O. This reveals improvement of reportedly preventable by avoiding mechanical ventilation, the mediastinal shift and adequate dilation of the left lung hyperinflation of the remaining lung, coughing on extuba- tion, and excessive suction within the chest drainage tubes Arterial blood gas analysis revealed pH 7.256, PaO [8–10]. As noted above, this spontaneous respiration 250.3 mmHg, and PaCO 60.3 mmHg during the admin- conflicted with the chest suction pressure because we had istration of 5 L/min of oxygen via face mask; thus, the chosen a lower pressure (− 7cmH O) than the setting typ- patient was transferred out of the operating room. Dur- ically used for postoperative drainage (− 15 cmH O). ing the administration of 4 L/min of oxygen via face Treatment of tension pneumothorax is undertaken to re- mask on arrival to the intensive care unit (ICU), arterial move excess air from the pleural cavity. In the present blood gas parameters were pH 7.352, PaO 200.3 mmHg, case, because a chest tube had already been inserted, we and PaCO 44.9 mmHg. Because no recurrence of increased its suction pressure to the typical level of − breathing discomfort was observed, the patient was 15 cmH O. It is necessary to distinguish impending discharged from the ICU the following day. There were tension pneumothorax from the occurrence of broncho- no postoperative complications after the patient exited pleural fistula (BPF). BPF is an air leak from the bronchi the operating room. The patient was discharged from due to the rupture of sutures after lobectomy, pneumon- the hospital on the 16th postoperative day without ectomy, or EPP. BPF has been reported to occur in 1.9% additional complications. of cases of EPP . BPF and dyspnea appear in close succession because pleural effusion of the affected lung is Discussion aspirated to the unaffected lung. Diagnostic character- We encountered a case of respiratory failure, presumably istics of BPF include a large quantity of sputum or caused by impending tension pneumothorax due to the hemosputum, as well as progressive subcutaneous em- inflow of air from the chest wall after EPP. Tension physema [12–14]. In addition, BPF is suspected of pneumothorax (a type of pneumothorax) presents with causing a sudden increase of air leakage from the an abnormal elevation of intrapleural pressure on the af- chest tube. Chest radiography and bronchoscopy are fected side, resulting in manifestations including collapse helpful in confirming a diagnosis of BPF [12–14]. of the affected lung, a low-set diaphragm, mediastinal First, a chest drain is inserted. Then, closure of BPF shift to the unaffected lung, and, when treatment is de- is needed in many cases [12–14]. In this case, there layed, reduced cardiac output due to impaired venous was little sputum, hemosputum, subcutaneous emphy- return [5, 6]. In this case, there was little circulatory sema, or air leak from the chest tube. Therefore, the collapse. When tension pneumothorax is left untreated, possibility of BPF was excluded. Sakuraba et al. JA Clinical Reports (2018) 4:45 Page 4 of 4 Other differential diagnoses should include post-pneu 4. 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The postpneumonectomy syndrome: clinical presentation and treatment. Eur J Ethics approval and consent to participate Cardiothorac Surg. 2009;35:319–24. This case report was approved by the institutional ethics committee (Ethics Committee, Juntendo University Shizuoka Hospital, Japan). Consent for publication Written informed consent was obtained from the patient for publication of anonymized case details and any accompanying images. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, 1129 Nagaoka, Izunokuni, Shizuoka 410-2295, Japan. Department of Anesthesiology and Pain Medicine, School of Medicine, Juntendo University, Tokyo, Japan. Received: 2 April 2018 Accepted: 30 May 2018 References 1. Omae T, Inada E. 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Published: Jun 6, 2018