PMC5421092_01
Preoperative CT scan of the neck. The preoperative CT scan of the neck shows no abnormalities. Shown are two different levels (a, b). Black arrows indicate thyroid tissue.
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The initial CT scan of the neck showed no abnormalities of the trachea (Figure 1).
X-rays during surgery showing pneumomediastinum and pneumothorax. First intraoperative chest X-ray revealed a small left-sided pneumothorax and a mild pneumomediastinum ((a) black arrows). Second intraoperative chest X-ray found that the left pneumothorax had decreased in size; however, a new right pneumothorax had developed ((b) black arrows).
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Subsequent intraoperative chest X-ray revealed a small left-sided pneumothorax and a mild pneumomediastinum (Figure 2). While the left pneumothorax had decreased in size, a new right pneumothorax had developed (Figure 2) and a second chest tube was placed.
X-ray on postoperative day 1 after extubation. The patient was extubated on postoperative day 1 as he met extubation criteria. Shown is the X-ay after extubation, indicating that the bilateral pneumothoraces had increased despite bilateral chest tubes.
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Postextubation chest X-ray showed proper chest tube position, but the pneumothoraces had increased (Figure 3).
Respiratory failure on postoperative day 2. Shown is the chest X-ray with bilateral patchy opacities (black arrows) after urgent reintubation. Together with a normal left ventricular function and poor oxygenation (PaO2 60 mmHg, FiO2 0.8, Horowitz quotient of 75), an acute respiratory distress syndrome (ARDS) was diagnosed, based on the Berlin definition.
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The heart rate [104/min] and the systolic blood pressure became elevated [180 mmHg], and the SpO2 dropped to 80% with a respirator rate of 41/min, indicating acute hypoxic respiratory failure and requiring reintubation (Figure 4). FiO2 0.8) in the absence of cardiac failure, the care team diagnosed a severe respiratory distress syndrome (ARDS) based on the Berlin definition (PaO2/FiO2 < 100 and PEEP 5+, Figure 4). Following intubation sequential bronchoscopies revealed no evidence for a tracheal injury.