Procedures: Student/Resident Case Report Poster - Procedures |

Contralateral Pneumothorax: An Unexpected Complication of EBUS-TBNA FREE TO VIEW

Kulothungan Gunasekaran, MBBS; Nazir Lone, MD; Peter Edmonds, BS; Swetha Murthi, MBBS; Shane Lloyd, MD
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Mary Imogene Bassett Medical Center, Cooperstown, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1033A. doi:10.1016/j.chest.2016.08.1139
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SESSION TITLE: Student/Resident Case Report Poster - Procedures

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that provides real time visualization and sampling of lymph nodes adjacent to the trachea and large bronchi. EBUS-TBNA has an overall complication rate of 1.4% (most commonly from pneumothorax, bleeding requiring intervention, sustained hypoxia, or airway injury).1 To our knowledge, no case of contralateral pneumothorax has been reported with EBUS-TBNA. Here we describe a case of contralateral pneumothorax as an unexpected complication of endobronchial ultrasound.

CASE PRESENTATION: A 73-year-old male with a newly diagnosed adenocarcinoma of the lung with Positron Emission Tomography (PET) scan-positive right hilar lymph nodes [Figure 1A] was referred to the pulmonary clinic for mediastinal staging. His pertinent history included oxygen dependent severe Chronic Obstructive Pulmonary Disease (COPD) and emphysema. He had no smoking or Tuberculosis exposure, but had occupational exposure to asbestos from 1970 -1990. During the procedure, a right hilar lymph node was found with difficulty and a single pass fine needle aspiration (FNA) was performed [Figure 1B]. No other biopsies were taken. Approximately 30 minutes after the procedure, the patient complained of left-sided chest discomfort and difficulty breathing. He was found to be tachypneic with oxygen saturation near 80%. An urgent chest x-ray (CXR) showed a left-sided pneumothorax[Figure 2A]. The patient underwent emergent chest tube placement with resolution of pneumothorax [Figure 2B].

DISCUSSION: Ipsilateral pneumothorax is a rare complication of EBUS-TBNA, whereas contralateral pneumothorax has not been reported before. Because pneumothorax without a biopsy is a rare complication, the possible causes have not been well described. Our patient developed contralateral pneumothorax due to positive pressure during ventilation causing rupture of emphysematous bulla. We speculate that this may have been due to a large EBUS scope wedging into a subsegmental lobar bronchi, which diverted the tidal volume during general anesthesia to the contralateral lung. Possible risk factors include a large tidal volume, dynamic inflation, and increased airflow obstruction. Since general anesthesia can obscure the presentation, it is important to communicate with the anesthesiologist about these serious complications, so that the tidal volume can be adjusted appropriately.

CONCLUSIONS: Contralateral pneumothorax is a rare and potentially fatal complication that can occur after EBUS-TBNA procedure. It is important to identify patients with a higher risk of complications, especially with advanced emphysema, who need to be monitored more closely after the procedure.

Reference #1: Eapen G , Shah A, X Lei X et al. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: results of the AQuIRE registry. Chest, 143 (4) (2013), pp. 1044-1053.

DISCLOSURE: The following authors have nothing to disclose: Kulothungan Gunasekaran, Nazir Lone, Peter Edmonds, Swetha Murthi, Shane Lloyd

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