P065: INTRAOPERATIVE VENTILATORY FAILURE DURING ONE-LUNG VENTILATION LEADING TO EARLY RECOGNITION OF BRONCHOPLEURAL FISTULA IN A TRAUMA PATIENT
Sebastian Camargo, DO; Kalina Nedeff, MD
HCA Kendall
Introduction/Background: Bronchopleural fistula (BPF) is a serious complication following thoracic trauma, associated with persistent air leak, impaired ventilation, and increased morbidity. Diagnosis may be delayed, particularly when initial bronchoscopy or imaging is inconclusive. Intraoperative ventilatory abnormalities observed by anesthesiologists may provide critical physiologic clues enabling earlier recognition and management.
Methods: We describe anesthetic management and intraoperative ventilatory findings in a mechanically ventilated trauma patient undergoing video-assisted thoracoscopic surgery (VATS), with emphasis on ventilatory mode performance and physiologic changes that raised concern for bronchopleural fistula.
Results: A 63-year-old male (BMI 23.5, ASA IV) presented following motorcycle collision with bilateral pulmonary contusions, rib fractures, bilateral pneumothoraces, thoracic spine fracture, and subdural hematoma. The patient was intubated with a 7.5 endotracheal tube and transported to the operating room for VATS. Lung isolation was achieved using a bronchial blocker, and the patient was positioned in right lateral decubitus for left-sided surgery.
During one-lung ventilation, oxygenation remained adequate (SpO2 93–100%) with tidal volumes ranging from 297–446 mL, peak inspiratory pressures of 22–29 cm H2O, and end-tidal CO2 between 44–52 mmHg. During thoracic irrigation, a large volume of fluid unexpectedly drained through the endotracheal tube, requiring immediate circuit disconnection and bronchoscopic suctioning.
Following this event and transition toward two-lung ventilation, progressive deterioration in delivered tidal volumes was observed despite stable ventilator settings and confirmed circuit integrity. Tidal volumes decreased from approximately 365 mL to 236 mL, and ultimately to 55 mL, while peak inspiratory pressures remained elevated at 27 cm H2O. End-tidal CO2 decreased from 39 mmHg to 34 mmHg, consistent with impaired alveolar ventilation. Ventilation improved with pressure-controlled ventilation and significantly improved after repositioning the patient from lateral decubitus to supine, with restoration of tidal volumes to approximately 498 mL and normalization of ventilatory parameters.
Postoperatively, the patient demonstrated persistent right-sided air leak requiring multiple chest tubes. Based on intraoperative ventilatory abnormalities and airway findings, anesthesiology raised concern for bronchopleural fistula. Subsequent clinical evaluation supported this diagnosis, and the patient was referred for bronchoscopic valve placement.
Discussion/Conclusion: This case demonstrates that sudden failure of volume-controlled ventilation, severe reduction in delivered tidal volumes despite stable airway pressures, and improvement with pressure-controlled ventilation may represent important physiologic indicators of bronchopleural fistula. These findings likely reflect preferential gas escape through the fistula during positive pressure ventilation. Anesthesiologists are uniquely positioned to detect these ventilatory abnormalities intraoperatively. Early recognition based on ventilatory mechanics may facilitate timely diagnosis and definitive management, particularly when conventional diagnostic modalities are initially inconclusive.