Postoperative pulmonary complication after neurosurgery: A case of unilateral lung collapse.

Pulmonary complications, especially postoperative pulmonary complications, are an important cause of morbidity and mortality in neurosurgical patients. Hypoxemia due to mucus plug causing lung collapse is a rare event. We report a case of a 40-year-old female with right cerebellopontine angle space occupying lesion, scheduled for elective craniotomy and tumor excision. The patient underwent surgery uneventfully and was shifted to Intensive Care Unit (ICU) for monitoring. Eight hours after extubation, she developed hypoxemia due to mucus plug resulting in left lung collapse. She was intubated, and mucus plug was aspirated through sterile endobronchial tube suction which resulted in reexpansion of the collapsed lung. The patient was managed with postural drainage, chest physiotherapy, and antibiotics and extubated after 24 h. This type of pulmonary complication may have a catastrophic course, especially in neurosurgical patients, if not diagnosed and managed in time.

INTRODUCTION

Pulmonary complications are a major cause of morbidity and mortality in neurosurgical patients. The common pulmonary complications in neurosurgical patients include pneumonia, postoperative atelectasis, respiratory failure, pulmonary embolism, and neurogenic pulmonary edema. Prevention and timely management of these complications can help to decrease the morbidity and mortality associated with pulmonary complications.[1] In fact, development of postoperative complications may also be associated with poor neurological outcome in many situations.[2] Therefore, prevention, timely recognition, and appropriate management of these assume great importance for the anesthetist and neurosurgeon. We report a case of postoperative hypoxemia due to mucus plug causing lung collapse in a patient, which was diagnosed and managed in time before it could have led to a catastrophic event.

CASE REPORT

A 40-year-old female weighing 50 kg, diagnosed as a case of right cerebellopontine angle space occupying lesion was scheduled for elective craniotomy and tumor excision. Her medical history revealed weakness of right upper and lower limbs for 2 months and right facial nerve palsy for 3 months. The patient was operated for space occupying lesion in brain 2 years back under general anesthesia, which was uneventful. All routine investigations were within normal limit. She had no other associated comorbid condition. Her chest radiograph and electrocardiograph showed normal study.

On the day of surgery, she was premedicated with glycopyrrolate 0.2 mg intravenous (i.v), injection ondansetron 4 mg i.v, and injection fentanyl 2 µg/kg i.v. General anesthesia was induced with propofol 2 mg/kg i.v and endotracheal intubation was facilitated with vecuronium bromide 0.1 mg/kg body wt. Anesthesia was maintained with nitrous oxide and oxygen mixture (50:50). Propofol and fentanyl infusion were titrated to a mean blood pressure of 60–80 mm Hg, and maintenance dose of vecuronium bromide was administered intermittently for muscle relaxation.

Intraoperative monitoring included electrocardiography, pulse oximetry, end tidal carbon dioxide, noninvasive blood pressure, and central venous pressure monitoring. The patient was stable throughout the procedure. The surgery lasted 3 h, and the intraoperative course was uneventful.

At the end of the surgical procedure, the patient was extubated in the operating theater after reversal of the residual neuromuscular blockade.

Postoperatively, the patient was conscious, coherent, and well oriented. The patient was shifted to ICU for postoperative monitoring. Eight hours after the surgery, the patient developed hypoxemia and oxygen saturation decreased from 98% to 85% with 100% FiO2. On auscultation, breath sounds were absent in left supraclavicular, mammary and scapular areas with crepitation present in the corresponding area. A portable chest radiograph was suggestive of left lung collapse [Figure 1]. The patient remained hemodynamically stable. With persistent hypoxemia and left lung collapse, an endotracheal intubation was planned, under the injection propofol, a cuffed endotracheal tube (ETT) of 7 mm internal diameter was passed under vision through vocal cord to mid tracheal position and then rotated 90° anticlockwise and advanced up to 24 cm mark to guide it to left main bronchus. After inflation of the cuff, gentle sterile endobronchial tube suction yielded a thick yellowish green mucus plug. A sudden improvement was seen in the respiratory movement. After improvement on auscultation of left lung, the ETT was withdrawn to midtracheal position after deflating the cuff. Oxygen saturation rose to 95%. Repeat chest radiograph was taken after 1 h showed complete expansion of the left lung [Figure 2]. Mechanical ventilation with supplemental oxygen was continued, and the patient was kept on fentanyl infusion. The patient was hemodynamically stable and maintained oxygen saturation. Bronchodilator nebulization, repeated suctioning, and chest physiotherapy were done to clear tracheobronchial tree. The patient was extubated the following day after T-piece trial, regaining protective airway reflexes and a normal arterial blood gas profile. On postextubation, the patient was able to maintain saturation to 98% on an oxygen mask, and on chest auscultation, bilateral equal air entry and normal vesicular breath sounds were heard. She was shifted to ward 2 days later with normal chest X-ray.

Figure 1

Collapsed left lung

Figure 2

X-ray posterior-anterior view: Re-expansion of left lung

DISCUSSION

Acute pulmonary collapse is common in the postoperative and ICU setting, especially in neurosurgery cases. It is prudent to be aware of and make certain simple strategies as part of the routine protocol of care in ICUs as well as ward patients, so as to reduce the various pulmonary complications in the postoperative period.[2] Patient in ICU has a tendency to retain secretions and are at a risk of lobar, segmental, or sub segmental atelectasis, which may be complicated by pneumonia.[3] Most common causes of acute pulmonary collapse include endobronchial intubation or blockage of the tube by secretions and blood or herniated cuff. Atelectasis due to mucus plug as a cause of hypoxemia is uncommon and may be potentially fatal.[4] Our report highlights the onset of hypoxemia associated with unilateral left lung collapse due to mucus plug. In our patient, the initial clinical presentation included sudden onset of hypoxemia with diminished chest movement and absent breath sound on the left side and chest radiograph suggestive of left lung collapse. Due to persistent hypoxemia and lung collapse, endotracheal intubation was performed. Before going ahead with fiberoptic broncoscopy, a trial of postural drainage was done. The tube was advanced to left main bronchus, after gentle sterile suction through ETT mucus plug was aspirated, and the patient improved clinically and radiologically, so fiberoptic bronchoscopy as planned earlier was not performed. While lung collapse and intraoperative hypoxemia have been reported previously, few involve mucous plugging and atelectasis.[56] We reported a case of successful reexpansion of lung following postural drainage of mucus plug causing left lung collapse. Although fiberoptic bronchoscopy is a gold standard to aid diagnosis and management, a trial of postural drainage may be life-saving.[78]

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Conflicts of interest

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