Cardiothoracic Surgery |

Spontaneous Pneumothorax With Extensive Subcutaneous Emphysema: A Rare Complication of Shoulder Arthroscopy FREE TO VIEW

Sarah Asghar, MD; Muhammad Azam, MD; Rudin Gjeka, MD; Alexander Adams, MD; Arham Barakzai, MD; Alaeddin Maeza, MD; Sarwan Kumar, MD
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Wayne State University, Rochester, MI

Chest. 2015;148(4_MeetingAbstracts):34A. doi:10.1378/chest.2278764
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SESSION TITLE: Cardiothoracic Surgery Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Arthroscopic shoulder surgery is a common orthopedic procedure, with 5.8-9.5% risk of complications. Respiratory complications are rare, and are mostly attributed to anesthesia or surgical technique. We present a case of spontaneous pneumothorax with extensive subcutaneous emphysema, presenting within 1-hour of shoulder arthroscopy.

CASE PRESENTATION: 51-year-old female without any co-morbid conditions, presented to the ER with sudden onset shortness of breath, dysphagia and dysphonia. She has no history of smoking or underlying lung problems. Patient underwent a right arthroscopy and rotator cuff repair for rotator cuff tear under general anesthesia as outpatient. Her symptoms started just 30 minutes after discharge. Vital signs were stable with oxygen saturation of 97% at room air. Physical examination showed no respiratory distress. There was decreased air entry with diminshed tactile vocal fremitus on the right chest wall. There were skin crepitations on palpation on the right side. CT chest and head & neck showed a large right pneumothorax and pneumomediastinum. There was extensive subcutaneous emphysema involving the right hemithorax extending into bilateral supraclavicular regions, neck, and anteromedial aspect of right arm. There was also an evidence of residual air in right shoulder joint. A right side chest tube was placed with good lung expansion. Patient continued to have an air leak during her hospital stay, hence was discharged home with Heimlich valve.

DISCUSSION: Spontaneous pneumothorax and subcutaneous and mediastinal emphysema are significant complications following shoulder arthroscopy. Mechanisms responsible for pneumothorax may include, rupture of parietal pleura by an external trauma to the chest wall; rupture of visceral pleura; or alveolar rupture, which can commonly occur by a rupture of bulla or bleb secondary to positive pressure ventilation. A direct injury to the trachea or esophagus from endotracheal intubation can also be a cause. Infusion pump system used in arthroscopy; intermittently pumps fluid into the cavity with simultaneous removal of fluid by suction, thus maintaining a constant pressure. Understanding of fluid dynamics suggests, a Bernoulli effect can potentially occur during surgery, which may create conditions favoring air entry into subacromial space. Our patient did not have any history of smoking or underlying lung pathology. Presence of air on CT in right shoulder communicating with subcutaneous pneumothorax along with large pneumothorax favors this to be likely cause of pneumothorax.

CONCLUSIONS: Heavy smoking and pulmonary comorbidities are important predisposing conditions to spontaneous pneumothorax following shoulder arthroscopy under general anesthesia. Both anesthesia-and surgery-related variables can be inferred as a cause of subcutaneous emphysema and pneumomediastinum.

Reference #1: Dietzel DP, Ciullo JV (1996) Spontaneous pneumothorax after shoulder arthroscopy: a report of four cases. Arthroscopy 12:99-102

DISCLOSURE: The following authors have nothing to disclose: Sarah Asghar, Muhammad Azam, Rudin Gjeka, Alexander Adams, Arham Barakzai, Alaeddin Maeza, Sarwan Kumar

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