Management of a Pneumothorax Found Intraoperatively During Emergent Surgery.

Pneumothorax is a potentially life-threatening condition that occurs when air enters the pleural cavity. There are numerous causes of pneumothorax, and healthcare providers must identify and treat the condition quickly to avoid elevated morbidity and mortality.  This report describes the case of an 87-year-old man with several comorbidities and a chronic tracheostomy on a ventilator who presented to the emergency department (ED) with bleeding at the tracheostomy site. Initial workup by otolaryngology (ENT) revealed hemostasis at the tracheostomy site and a retrocardiac opacity suspicious for pneumonia, so he was admitted to the intensive care unit (ICU). The patient was later noted to have oozing at the tracheostomy site and difficult ventilation, and a bronchoscopy revealed clots in the trachea. Ventilation became increasingly difficult, and the patient went into cardiopulmonary arrest, requiring chest compressions and defibrillation. After clot removal and spontaneous circulation was achieved, the patient continued to have persistent desaturations and was taken to the operating room (OR) by ENT for surgical exploration of the upper airway. During the surgery, two intraoperative chest X-rays (CXRs) taken 1.5 hours apart revealed a right pneumothorax. The surgeon opted to postpone chest tube insertion until after the procedure, and the pneumothorax was successfully decompressed in the medical intensive care unit (MICU) after the completion of the surgery. The patient returned to baseline health.  Our report demonstrates an uncommon case of pneumothorax discovered intraoperatively during emergent surgery. Pneumothoraces can cause rapid deterioration of hemodynamic stability and need to be identified quickly by providers. In the context of risk factors such as recent chest compressions, physicians should maintain high clinical suspicion for pneumothorax.