SPONTANEOUS primary pneumothorax is common in tall, asthenic males between ages 10 and 30 yr.1
Initial mode of therapy is nonoperative with a recurrence rate of 50%. Hitherto, recurrent pneumothorax was treated with thoracotomy and wedge resection of pulmonary bullae using a double-lumen endotracheal tube and single lung ventilation. Bullectomy is now routinely performed via
A 19-yr-old man (64 kg, 188 cm) with a history of left spontaneous pneumothorax was admitted after complaints of sudden pleuritic chest pain and dyspnea. Chest radiograph revealed left-sided pneumothorax (fig. A
). A pleural drain was inserted, and he was scheduled for video-assisted thoracic surgery and bullectomy.
After induction with propofol, fentanyl, and rocuronium, the trachea was intubated with a single lumen, cuffed endotracheal tube. Anesthesia was maintained with desflurane in 100% oxygen. He was placed in a right lateral decubitus position. To aid surgical visibility, carbon dioxide, 7–10 mmHg, was insufflated into the pleural cavity and the patient’s tidal volumes reduced to 5 ml/kg. Mechanical breaths were set to a rate of 30–35 breaths/minute to compensate for hypercarbia caused by low tidal volumes. Apical bullae were identified via
thoracoscopy, and bullectomy was performed (fig. B
) followed by chest tube placement and uneventful trachea extubation. The patient recovered without incident in the postanesthesia care unit and was discharged home on postoperative day 3. Video-assisted thoracoscopic bullectomy is possible with two lung ventilation, minimal tidal volumes, and an increased respiratory rate to compensate for hypercarbia.