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Treatment for pulmonary barotrauma8/25/2023 A thoracostomy tube should then be placed to allow air to be continuously removed until the ruptured alveoli can seal to prevent the reoccurrence of a tension pneumothorax. Once the intrathoracic pressure is relieved, arterial blood pressure and oxygen saturation will improve. If a pneumothorax is suspected, positive pressure ventilation should be immediately discontinued and thoracocentesis performed for emergency decompression of the chest. It is therefore important that the clinician is aware of the potential risk for a pneumothorax based on the patient history and potential predisposing conditions. Pneumothorax may only become evident on cardiopulmonary collapse. On auscultation, lung sounds may be absent or significantly diminished.Įarly recognition of clinical signs can be hindered in cases in which the patient’s overall condition is already compromised (eg, patient in shock, with hypovolemia, and/or with significant intraoperative blood loss). The patient becomes more difficult to ventilate as lung compliance decreases and chest wall movement is diminished. As the pneumothorax evolves to a tension pneumothorax and venous return is compromised, severe hypotension and hypoxemia occurs. The high-pressure intrathoracic environment that soon develops limits lung expansion and, most importantly, prevents venous return to the heart, leading to cardiovascular collapse.Īs the lungs’ ability to expand decreases and atelectasis increases, a change in breathing pattern typically occurs, followed by dyspnea and a decrease in oxygen saturation. ![]() As the lung tissue recoils during exhalation, air cannot escape via its entry path and becomes trapped outside the lungs in the thoracic cavity. In a one-way valve mechanism, air leaks out during lung inflation. During anesthesia, a closed pneumothorax can rapidly evolve to a tension pneumothorax. Awareness and early recognition are key to a successful outcome. Pneumothorax is a life-threatening complication of barotrauma. The device will alarm when a dangerous breathing circuit pressure occurs (independent of cause), providing the clinician time to intervene. In addition, it can be used with both rebreathing and nonrebreathing systems with spontaneous or mechanical ventilation. This device provides an audible alarm when the breathing circuit pressure reaches a set level (typically 20 cm H2O). Although this can be useful during spontaneous ventilation, it does not completely eliminate the risk, as the original pop-off valve will still need to be closed (and opened afterward) if mechanical ventilation is to be used or during the process of pressure checking the anesthesia machine for leaks. Once the button is released, flow through the valve is automatically re-established, minimizing the risk for forgetting to reopen the original pop-off valve, as it will always be left open. When the top button of the valve is pushed, flow out of the pop-off valve is occluded and a manual breath can be administered. This device can be attached to the outflow port of the anesthesia machine’s original pop-off valve. Most anesthesia-associated barotrauma events (and resulting pneumothorax) can be avoided through both a functional understanding of the anesthesia machine and the presence of safety features designed to prevent harmful conditions or alert the team if such conditions arise, including: Because the ventilator’s driving pressure (65-75 cm H 2O) prevents the expansion of the bellows until breathing system pressures overcome the driving pressure, activation of the flush valve at this time (eg, to reinflate the bellows after a brief disconnection) would direct all the volume and resulting pressure to the breathing circuit. During the inspiratory phase, the ventilator’s driving pressure actively compresses the bellows to deliver a breath, and the ventilator’s exhaust valve is closed. ![]() Similarly, if the oxygen flush valve is used during the inspiratory phase of mechanical ventilation, the patient’s lungs may be exposed to excessive pressure and overdistension. Therefore, use of the flush valve while a patient is connected to a nonrebreathing system transmits excess volume and pressure directly to the patient’s airway and lungs. 3,4 A nonrebreathing system (eg, Bain breathing system) has a relatively small inner volume and little compliance. ![]() The oxygen flush valve allows oxygen at high pressure and volume into the breathing system (35-70 L/min with a pressure of 45-60 pounds per square inch gauge, which becomes approximately 1 L/s into the breathing system). Excessive inflow can occur from improper use of the oxygen flush valve, aggressive ventilator settings (high airway pressures and tidal volumes), and/or inappropriate connection of oxygen tubing (meant for oxygen insufflation via open mask) to a cuffed endotracheal tube, laryngeal mask airway, or other airway device without the ability to allow excess gas to vent.
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