Spontaneous pneumothorax in early pregnancy: Successful management by thoracoscopy

A 28-year-old, 12 to 14 week primigravida presented with a 20-month history of recurrent spontaneous left pneumothoraces. The patient was a nonsmoker and had no other known risk factors for her pulmonary problems. She was previously healthy. She had experienced two episodes of pneumothoraces prior to her pregnancy and an additional five episodes during the past 3 months. Each previous episode of pneumothorax had been treated by chest tube drainage. Because of the failure to prevent recurrence with conservative management and the patient’s pregnancy, surgical intervention was recommended. The patient was brought to the operating room without premedication. Monitors included an electrocardiogram, a noninvasive blood pressure device, pulse oximetry and end-tidal carbon dioxide. This group’s practice is not to use an arterial line or central venous pressure catheter for thoracoscopic procedures, and these monitors were not used in this case. A stethoscope was used to monitor fetal heart tone. A left chest tube, attached to suction, was present and functioning. Following preoxygenation, general anesthesia was induced with sodium thiopental (250 mg, IV) and fentanyl (200 ug, IV). Muscle relaxation for tracheal intubation was achieved with succinylcholine (80 mg, IV). Her trachea was intubated with a 39F left double-lumen endobronchial tube. The bronchial lumen was advanced into the left main bronchus and its position was confirmed by physical examination and careful auscultation. The endobronchial lumen of the double-lumen tube was immediately clamped proximally and its lumen was opened distal to the clamp. This isolated the left lung. The patient’s right lung was ventilated with a tidal volume of 600 mL (approximately 10 mL/kg). Once successful separation of the lungs was achieved, the chest tube was removed. Anesthesia was maintained with isoflurane (1%) in oxygen. No further opioid agents were given. Vecuronium was administered for muscle relaxation. The patient was placed in the right lateral decubitus position. The position of the double-lumen tube was reconfirmed by physical signs and careful auscultation. A pneumothorax was then created on the left side by introducing an 1 l.O-mm thoracoport through the chest wall, opening the thorax to atmospheric pressure. Once the left lung collapsed, a lO.O-mm thoracoscope was inserted through the port and the chest cavity was visually inspected by a camera located at the proximal end of the thoracoscope. Two blebs were immediately identified at the apex of the lung. The left lung was partially insufflated with oxygen, but no other blebs were noted. Using the camera to identify the location of the apical blebs, a 5.0-mm port was placed through the chest wall for introduction of instruments to grasp the lung. Posteriorly, another ll.O-mm port was placed for insertion of a stapler (Endo GIA 3.5 Autosutures, United States Surgical Corp, Norwich, CT). The blebs were stapled off and the resected tissue removed. Partial reinflation of the left lung under direct vision using the thoracoscope confirmed no further gas leak from the two blebs and the absence of additional blebs. An argon-beam coagulator was then used for pleural sclerosis. The argon beam was directed at the apex of the chest cavity in the area where the blebs had been resected. A 28F straight chest tube was inserted and attached to water seal suction. The left lung was then fully reinflated. Muscle relaxation was then reversed with glycopyrrolate (0.5 mg, IV) and neostigmine (3.0 mg, IV). Breathing oxygen, she awoke from general anesthesia shortly after the isoflurane was discontinued. Her trachea was extubated in the operating room. Both the patient and her fetus tolerated the procedure. Her blood pressure and heart rate remained within 20% of baseline during the entire procedure. With an inspired oxygen concentration of 1.0, her hemoglobin remained 100% saturated throughout the procedure. End-tidal carbon dioxide measurements were between 32 and 36 mmHg. Fetal heart rate ranged between 145 to 160 beatsimin. Immediately after admission to the postanesthesia care unit the patient complained of severe left-sided chest pain, which increased with inspiration. The severe pleuritic pain, which limited her ability to take deep breaths and to cough, was refractory to morphine (12 mg, IV) given over 30 minutes. Therefore, the chest tube was clamped and 1.5% lidocaine without epinephrine (20 mL) was injected through it into the left chest. The patient experienced immediate and nearly complete pain relief for 90 minutes. When the pain began to recur an additional dose of 1.5% lidocaine without epinephrine (20 mL) was given through the chest tube with alleviation of the chest pain. The patient did not experience any complications or side-effects from the lidocaine. Following discharge from the postanesthesia care unit she required small doses of IV morphine via a PCA pump for additional analgesia. The patient was discharged home on the second postoperative day on oral hydrocodone (Vicodin) for analgesia. The remainder of the pregnancy was uncomplicated. There were no further recurrences of pneumothorax. Six months later she delivered a healthy full-term infant.