Perioperative Management Challenges for Post-Tuberculous Stage-III Empyema with Massive Pneumothorax Mimicking Vanishing Lung Syndrome: A Case Report

Roopali Phulli; Habib Md Reazaul Karim; Mahesh S Kurwe; Manu P Kesavankutty; Klein Dantis

doi:10.18502/aacc.v9i6.14454

Roopali Phulli Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India.
Habib Md Reazaul Karim Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India.
Mahesh S Kurwe Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India.
Manu P Kesavankutty Department of Anaesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences-Raipur, India.
Klein Dantis Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences-Raipur, India.

DOI: https://doi.org/10.18502/aacc.v9i6.14454

Keywords: Tuberculosis; Video-assisted thoracoscopic surgery (VATS); Lung isolation techniques; Complications

Abstract

Surgical resection is frequently the intervention required for post-tuberculous empyema or other sequels. However, pneumonectomy may not be feasible in some situations, and video-assisted thoracoscopic surgery (VATS) plays a role in such a scenario. Whether a patient undergoes open resection of VATS, isolation of infected lung is integral to one-lung ventilation and better access to the surgical field, and a double-lumen tube (DLT) remains the preferred choice. Difficulties in DLT placement after pneumonectomy are reported; however, failure to isolate a lung by appropriately placed DLT is scarce or absent. A 28-year cachectic gentleman with poor preoperative lung function was suffering from endobronchial tuberculosis. He also had one episode of tuberculosis twelve-year back. At presentation, he had a massive pneumothorax and stage-III empyema as a sequel, including a rare finding of plastered mediastinum mimicking vanishing lung syndrome. He underwent uniportal-VATS under general anesthesia using one-lung ventilation. Complete lung destruction from active tuberculosis and its sequel leading to the plastered mediastinum and deformed airway pose a significant lung isolation challenge. U-VATS can be considered for therapeutic purpose where standard thoracotomy and pneumonectomy is contra-indicated. However, lung isolation in such patients is tricky and poses a risk. The present case highlights the challenges faced with lung isolation using a DLT and discusses the probable remedy to these problems.