DP63: ANESTHETIC MANAGEMENT OF A PREGNANT PATIENT WITH LYMPHANGIOLEIOMYOMATOSIS AND TENSION PNEUMOTHORAX REQUIRING CHEST TUBE PLACEMENT
Ryan A Skelly, MD, MBA; Adam Henderson, BS; David Abia-Trujillo, MD, MB; Dennis J Warfield Jr, MD, FASA
Mayo Clinic
Introduction / Background: Lymphangioleiomyomatosis (LAM) is a rare progressive cystic lung disease affecting women of reproductive age, frequently complicated by recurrent spontaneous pneumothorax with increased incidence and severity during pregnancy (McCarthy, 2021). Pregnancy-related physiological changes, including decreased functional residual capacity and increased oxygen consumption, further reduce pulmonary reserve which heightens vulnerability to hypoxemia and hemodynamic instability. Tension pneumothorax represents a life-threatening emergency requiring prompt decompression, typically performed awake or with minimal sedation. Induction of general anesthesia in patients with compromised pulmonary reserve carries substantial risk of cardiovascular collapse, particularly in the setting of positive-pressure ventilation. We describe the anesthetic management of a pregnant patient with LAM and evolving tension pneumothorax who refused awake or moderately sedated intervention requiring urgent pleural decompression under general anesthesia.
Methods: A 25-year-old pregnant woman with a medical history significant for LAM, tuberous sclerosis, epilepsy, recurrent pneumothoraxes, substance use disorder, major depressive disorder, and anxiety was admitted for evaluation of vaginal bleeding. On hospital day two, she developed acute dyspnea. Chest radiography revealed a large left-sided pneumothorax with mild rightward mediastinal shift, concerning for evolving tension physiology (Fig. A). Pulmonology recommended urgent chest tube placement; however, the patient refused awake or moderately sedated intervention despite extensive counseling. In the interventional pulmonology suite, the anesthetic strategy prioritized preservation of spontaneous ventilation, avoidance of airway instrumentation and positive-pressure ventilation with maintenance of hemodynamic stability. Anesthetic induction was achieved with slowly titrated intravenous doses of ketamine 10mg (20 mg total), remimazolam 2mg (8 mg total), and dexmedetomidine 4mcg (8 mcg total). Supplemental oxygen was administered throughout the procedure via face mask with capnography. Anesthesia was maintained with subsequent doses of 10 mg IV ketamine (30 mg total) and 2 mg IV remimazolam (12 mg total) while maintaining spontaneous ventilation. Needle decompression followed by placement of a 14-French chest tube (Cook Medical, Thal-Quick kit) in the 2nd intercoastal space, mid-clavicular line using the Seldinger technique was performed by the interventional pulmonology team after the patient’s skin was anesthetized with local anesthetic (Anderson, 2021).
Results:
Figure A: Left-sided tension pneumothorax prior to intervention. Figure B: Left-sided percutaneous pig-tail chest catheter with resolution of tension pneumothorax.
Discussion / Conclusion: This case highlights anesthetic challenges associated with managing tension pneumothorax in a pregnant patient with LAM who declined standard awake or minimally sedated chest tube placement. A carefully titrated intravenous anesthetic technique utilizing ketamine, remimazolam, and dexmedetomidine provided adequate procedural conditions while preserving spontaneous ventilation and hemodynamic stability, thereby minimizing the risk of cardiovascular collapse associated with deep anesthesia and positive-pressure ventilation. This approach may be considered in select high-risk obstetric patients requiring urgent pleural decompression when conventional techniques are not feasible. This case report underscores the importance of individualized anesthetic planning and multidisciplinary collaboration in a unique critical scenario.
Citations:
McCarthy C, et al. Lymphangioleiomyomatosis: pathogenesis, clinical features, diagnosis, and management. Lancet Respir Med. 2021 Nov;9(11):1313-1327. doi: 10.1016/S2213-2600(21)00228-9. Epub 2021 Aug 27. PMID: 34461049.
Anderson D, et al. Comprehensive Review of Chest Tube Management: A Review. JAMA Surg. 2022;157(3):269–274. doi:10.1001/jamasurg.2021.7050