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Bilateral Pneumothoraces Complicating Tracheal Insufflation in a Nonintubated Adult

Mirza, Muhammad MD; Baram, Daniel MD

doi: 10.1097/LBR.0b013e318175331d
Case Reports

Tracheal insufflation is useful during bronchoscopy to improve oxygenation. A 75-year-old woman developed seizure during bronchoscopy resulting in desaturation. Oxygen was insufflated into the trachea; however, jaw clenching and tongue swelling limited her ability to exhale resulting in bilateral pneumothoraces. Pneumothorax owing to insufflation has been reported in children and during mechanical ventilation, especially during targeted bronchial maneuver. Bronchoscopists need to be aware that seizure can compromise exhalation sufficiently to make insufflation dangerous.

Division of Pulmonary/Critical Care/Sleep Medicine, Stony Brook University Medical Center, NY

There is no conflict of interest.

Reprints: Daniel Baram, MD, T-17 040 HSC, Stony Brook, NY 11794-8172 (e-mail:

Received for publication February 14, 2008; accepted February 25, 2008

Tracheal insufflation through the suction port of a bronchoscope can be useful in improving oxygenation and facilitating ventilation by washing out the tracheal dead space. Generally, it is safe with only rare complications reported in children.1,2 We report a case of bilateral pneumothoraces after tracheal oxygen insufflation in a nonintubated adult.

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A 75-year-old woman presented with malaise and weight loss. She was an exsmoker with a 50-pack-year smoking history. She was found to be hyponatremic with serum sodium of 120 mEq/L. Computerized tomography scan demonstrated a left hilar mass extending into her mediastinum (Fig. 1), and a bronchoscopy was performed for the tissue diagnosis of suspected small cell carcinoma.



In the endoscopy suite, the patient received lidocaine nebulization and was sedated with intravenous administration of 2 mg of midazolam and 50 μg of fentanyl. Lidocaine was instilled topically as well; in all 120 mg of lidocaine was administered. Endobronchial examination via transnasal route demonstrated a nodular irregularity at the level of the left carina. A single pass transbronchial needle aspiration was performed. During the rapid on-site sample processing, the patient was noted to have muscle jerks in both arms and legs, and to become unresponsive. She clenched her jaw, biting her tongue, which began to swell. She was given an additional 2 mg of midazolam for suspected seizure. Her oxygen saturation began to decrease, and 10 L/min of oxygen was insufflated via the working channel of the flexible bronchoscope. Her oxygen saturation promptly returned to 100%.

Her seizures ended in approximately 5 minutes and her jaw relaxed. However, she was noted to become increasingly tachycardic and her oxygenation again began to worsen. Her chest configuration became asymmetric with limited excursion on the right; subcutaneous air was noted over her chest wall. A right-sided chest tube was placed urgently with normalization of her vital signs and oxygenation. Chest radiograph demonstrated subcutaneous air, right chest tube, and a small pneumothorax on the left (Fig. 2). A left chest tube was placed. There was no air leak noted after 1 hour; both chest tubes were removed without difficulty at 48 hours.



Pathology reported malignant small blue cells, but there was insufficient sample to distinguish carcinoma from lymphoma. Second bronchoscopy was performed without incident; cytopathology and histopathology confirmed small cell carcinoma. Magnetic resonance imaging of the brain was normal; positron emission tomography scan showed disease only in the right thorax. She received treatment for limited small cell with concurrent chemotherapy and radiation.

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This patient developed bilateral tension pneumothoraces during bronchoscopy as a result of bronchoscopic insufflation. Insufflation involves the direct administration of oxygen into the trachea. This improves oxygenation and facilitates ventilation by clearing the tracheal dead-space of carbon dioxide. Key to performing this safely is ensuring the escape of the gas, as up to 10 L/min is administered. During this patient's seizure, her mouth was sealed from the jaw clenching and tongue swelling, one nostril was obstructed by the bronchoscope, and the other nostril was apparently not sufficiently patent.

There are 2 prior reports of pneumothorax owing to tracheal insufflation in the literature, both occurred in children: one during rigid bronchoscopy,3 the other during flexible bronchoscopy through an endotracheal tube.2 In both cases, the procedure directly compromised the airway diameter; the risk of this is higher in children and neonate than in adults due to the smaller caliber of their trachea.

Insufflation during bronchoscopy through an endotracheal tube can cause this complication, as the scope obstructs much of the cross-sectional area. Pneumothoraces have been reported owing to jet ventilation through an airway exchange catheter, most likely owing to this mechanism.4–6 Even short insufflations may deliver sufficient gas to cause pneumothorax. Deflation of the endotracheal tube cuff may reduce the risk of pneumothorax, similar to the cuff-leak technique used during high-frequency oscillation.7

Targeted bronchial insufflation has been described as a treatment for lobar collapse during mechanical ventilation.8,9 It differs from tracheal insufflation as it involves sealing of a lobar or segmental bronchus and raising airway pressure above the critical opening pressure to expand atelectatic lobe. Reported complications include pneumothorax and air embolism.10,11 Specific techniques have been described to minimize the risk of overinflation.12,13

Severe hyponatremia likely contributed to the seizure that initiated this patient's complication. Her sodium improved to 129 before the second bronchoscopy, which was uneventful; her sodium normalized after chemotherapy and she had no further seizures. Magnetic resonance imaging did not demonstrate brain metastases. Lidocaine toxicity can lead to seizures but the dose she received was too small to cause the complications.14–16

Pneumothoraces complicating bronchoscopy generally occur during transbronchial biopsy.17,18 Pneumothorax has been reported after transbrochial needle aspiration but only rarely.19,20 In this case, the transbrochial needle aspiration was performed into the left hilum making it very unlikely to have been the cause of a right pneumothorax.

We report the first case of pneumothorax owing to tracheal insufflation in a nonintubated adult; it occurred during a seizure that sealed her mouth limiting her ability to exhale the insufflated oxygen. Before using tracheal insufflation, the endoscopist must confirm that there is sufficient airway to allow full escape of the insufflated gas.

Furthermore, heightened vigilance should also be exercised during pediatric bronchoscopy, especially when the instrument is introduced via an endotracheal tube. In addition, tongue biting during a seizure can sufficiently seal the oral airway and increase risk for complications from tracheal insufflation.

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flexible bronchoscopy; complication; pneumothorax; tracheal insufflation

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