Pneumothorax

[nctxil]

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84 y/o F with dementia that needs an ORIF of the shoulder. HTN, CAD, etc...
She has a 20% pneumothorax of the right lung. Any suggestions on how you would proceed?

A) Just do the case, she is going to die anyway
B) Don't do the case, she is going to die anyway
C) Wait a week or two and see if the pneumo resolves and reassess
D) Put a chest tube in and proceed if the pneumo hasn't resolved in a week
E) None of the above

Thanks for your input. I have heard various ideas and looking to see what other think.

 

[pd4emergence]

Where I am, any ptx pt gets evaled by surgery, if they don't plan on a chest tube, and the surgery needs to go before waiting to see if the ptx is resolving, I would proceed, preferably with an lma, try to keep positive pressure vent to a minimum and do my best to limit peak pressures, any signs of worsening ptx and she's getting a chest tube.

 

[Oggg]

If her dementia permits, an interscalene blk would be useful in reducing the pain/stress of surgery, but of course only if it's the right shoulder due to phrenic paresis.

The problem with the LMA idea is that if you need to convert to ETT during the case it may be impossible to do without ripping the drapes off. If you decide on ETT to start, you could let the patient breathe spontaneously, but again, if you need to do PPV, you'll want a chest tube preop (rather than relying on a needle thoracostomy prn)

 

[Oggg]

F) LMA -> chest tube under anesthesia, then ORIF

 

[Noyac]

Is the ORIF in the lateral position or beach chair?

I assume the PTX is the same side as the broken shoulder, right?

THere are so many ways to skin this cat.

 

[nctxil]

Is the ORIF in the lateral position or beach chair?

I assume the PTX is the same side as the broken shoulder, right?

THere are so many ways to skin this cat.

Beach chair
Ptx same side as fracture

 

[Oggg]

practice the plumb bob landmark based supraclav block on her, since ptx doesn't matter, cuz you're going to put in a chest tube anyways... (j/k)

 

[DScully]

Can she tolerate one-lung ventilation?

what about chest tube pre-op and then double lumen tube intraop so that you could potentially do one lung ventilation if she can tolerate it or even with two ventilators with different settings?

I have never seen it done before though...

 

[Noyac]

Can she tolerate one-lung ventilation?

what about chest tube pre-op and then double lumen tube intraop so that you could potentially do one lung ventilation if she can tolerate it or even with two ventilators with different settings?

I have never seen it done before though...

Why?

I'm not following your logic here. You would place a CT and then go to one-lung ventilation? I understand that you don't want to make the lung worse possibly but the case won't be that long and positive pressure won't delay her lung healing for this short time.

Personally, CT or not I would keep her spontaneously breathing with an ETT and a little support. I do LMA's all the time in beach chair position but I wouldn't in this one.

 

[DScully]

Sorry...I wasn't thinking clearly.

I guess if the patient has chest tube pre-op, then you can do this case similar to a regular case (eg. ETT with volume control ventilation). If the patient does not have chest tube pre-op and if for some surgical reason, pt needs positive ventilation (eg being on the vent), then I would probably try double lumen...although I have to confess, I cannot think of a good reason that one would need to paralyze the patient for shoulder surgery.

Why wouldn't you do this case with LMA?

 

[Noyac]

Sorry...I wasn't thinking clearly.

I guess if the patient has chest tube pre-op, then you can do this case similar to a regular case (eg. ETT with volume control ventilation). If the patient does not have chest tube pre-op and if for some surgical reason, pt needs positive ventilation (eg being on the vent), then I would probably try double lumen...although I have to confess, I cannot think of a good reason that one would need to paralyze the patient for shoulder surgery.

Why wouldn't you do this case with LMA?

You could easily do this case with an LMA I just wouldn't bc of the obvious chest trauma and the possiblity of needing intubation which would be more difficult in beach chair position and it would interfer with the surgery.

I would do pressure control (you know that vol control will deliver more pressure, right) or spont with little to no peep and low pressure.

BTW, chest tube placement is not an indication for DBL ETT. I dont see any reason for a DBL ETT in this case at all.

 

[fabfive5]

You could easily do this case with an LMA I just wouldn't bc of the obvious chest trauma and the possiblity of needing intubation which would be more difficult in beach chair position and it would interfer with the surgery.

I would do pressure control (you know that vol control will deliver more pressure, right) or spont with little to no peep and low pressure.

BTW, chest tube placement is not an indication for DBL ETT. I dont see any reason for a DBL ETT in this case at all.

There is no reason for a DLT....way way overkill....are you in academics??? 🙄 😀

Find out WHY she has a pneumo. Is it getting bigger? Resolving? Do the surgeons know? (you'd be surprised).

I agree with the interscalene block.

If the pneumo is stable/resolving, do an LMA
If pneumo getting bigger, call your friendly surgeon for an elective CT....an urgent/emergent CT is not fun (been there, done that).

 

[epidural man]

F) LMA -> chest tube under anesthesia, then ORIF

Why not just send her to IR for a tiny pneumodart? Chest tubes hurt.

 

[DScully]

are you in academics??? 🙄 😀

Well...since I am still a resident, I don't really have anywhere else to go beside staying in academia...😉

 

[Oggg]

IR chest tube would be fine too if they aren't busy.

 

[2win]

IR chest tube would be fine too if they aren't busy.

What about a chest tube placed by you and the regular general anesthesia???
Why to call IR?
I am sometimes amazed about the false problems and headache without reasons...
2win

 

[2win]

Can she tolerate one-lung ventilation?

what about chest tube pre-op and then double lumen tube intraop so that you could potentially do one lung ventilation if she can tolerate it or even with two ventilators with different settings?

I have never seen it done before though...

Chest tube - yes.
Double lumen intraop? Why?
Ventilators with two different settings????
Could you please justify the reason?