Correct!
3. You should suspect a pneumothorax
Fluoroscopy confirmed the diagnosis of a moderate sized pneumothorax. The virtual-anatomical dissociation was created by the collapsed lung. Airways that were closer to the chest wall were now retracted towards the hilum, the takeoff of the posterior segment of the right upper lobe was now where the takeoff of the right upper lobe used to be.
Electromagnetic navigation bronchoscopy matches computed tomography (CT) images to the real anatomy of the patient during bronchoscopy providing real time GPS like guidance to allow accurate sampling of peripheral lung nodules or masses. At the beginning of the procedure the patient is placed on a location board with three sensors on the chest. The location board creates an electromagnetic field within which the patient sensors and the locatable guide can be located. Following this, the bronchoscope with a locatable guide inserted through its working channel is advanced into the airway. Using the main carinas and airways the real patient anatomy is matched to the CT anatomy. This process is called registration. Once registration is finished the locatable board and the sensors can account for patient respiratory motion (1).
The most common complication of the procedure is pneumothorax occurring in 3.5-7.5% of the cases in the published literature (1). The most common symptoms of pneumothorax are chest pain and dyspnea. In patients who are anesthetized and intubated, such as ours, changes in respiratory mechanics are the most common clinical clues for pneumothorax. The changes in respiratory mechanics include increased peak and plateau pressures, unanticipated decreases in tidal volume, asymmetric chest rise, decreased breath sounds and in advanced cases pulsus paradoxus and obstructive shock (2). This is to our knowledge the first report of virtual-anatomical dissociation during electromagnetic navigation bronchoscopy as a sign of pneumothorax.
Rodrigo Vazquez-Guillamet MD, Emily Horn MD, Renee Sarver RRT, Lana Melendres MD
Division of Pulmonary, Critical care and Sleep Medicine,
University of New Mexico School of Medicine
Albuquerque, NM USA
References