Sudden Onset Unilateral Pulmonary Oedema during Thoracotomy

Abstract

Sudden onset of frank pulmonary oedema intraoperatively is a rare and worrying occurrence. We wish to report a case of unilateral pulmonary oedema that occurred during thoracotomy, and discuss the possible mechanisms. CASE REPORT A 26-year-old previously healthy black male was admitted to hospital for investigation of left-sided pleuritic chest pain, fever and malaise. He was found to have a left pleural effusion and left lower lobe consolidation. Extensive investigation revealed no cause for the effusion which later became infected, possibly as a complication of pleural aspiration and biopsy. The empyema did not resolve with antibiotics and percutaneous chest drainage and he was therefore scheduled for thoracotomy and decortication of the left lung. At the preoperative visit the patient was afebrile and generally well, despite the empyema and extensive collapselconsolidation of the left lung (Figure 1). After induction of anaesthesia, the trachea was intubated with a 41 FG left-sided double-lumen endobronchial tube (Mallinckrodt "Broncho-Cath"). The tube was positioned using the standard sequential clamping technique with inspection of chest expansion and auscultation of breath sounds. This was repeated after positioning the patient on his right side. It was noted that air entry to the consolidated lung was limited to the apex. Both lungs were ventilated with 33% oxygen in nitrous oxide and enflurane. Paralysis was maintained with atracurium, and continuous monitoring included invasive intra-arterial blood pressure and pulse oximetry. Arterial blood gases after twenty minutes'