Diaphragmatic Herniation with Pneumothorax Due to Barotrauma – Lessons to Learn: A Case Report

Jiao Ran; Peng Ji

doi:10.36502/2024/ASJBCCR.6354

Asploro Journal of Biomedical and Clinical Case Reports
ISSN: 2582-0370
Article Type: Case Report
DOI: 10.36502/2024/ASJBCCR.6354
Asp Biomed Clin Case Rep. 2024 Jun 28;7(2):158-61

Abstract

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Diaphragmatic Herniation with Pneumothorax Due to Barotrauma – Lessons to Learn: A Case Report

Jiao Ran¹, Peng Ji^2*
¹Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
²Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China

Corresponding Author: Peng Ji
Address: Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, No. 37, Guoxue Alley, Chengdu 610041, Sichuan, China.
Received date: 27 May 2024; Accepted date: 21 June 2024; Published date: 28 June 2024

Citation: Ran J, Ji P. Diaphragmatic Herniation with Pneumothorax Due to Barotrauma-Lessons to Learn: A Case Report. Asp Biomed Clin Case Rep. 2024 Jun 28;7(2):158-61.

Copyright © 2024 Ran J, Ji P. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Diaphragmatic Herniation, Pneumothorax, Pneumoperitoneum, Mechanical Ventilation, Barotrauma

Abstract

Diaphragmatic hernia is usually congenital or follows thoracoabdominal injury. Diaphragmatic hernia combined with pneumothorax is a rare combination in the clinical setting, where pneumothorax is usually secondary to hollow viscera perforation in the long-term complications of diaphragmatic herniation or rupture of ectopic endometrium over the diaphragm during menstruation. Unlike the aforementioned conditions, we describe a 67-year-old man with chronic diaphragmatic hernia who suffered from pneumothorax and pneumoperitoneum secondary to pulmonary bulla by barotrauma during mechanical ventilation. Computed tomography showed scattered free gas in the thoracic and abdominal cavities, while there was no tenderness and rebound tenderness. The patient was managed conservatively with low PEEP and a lung-protective mechanical ventilation strategy. Finally, the oxygenation index gradually rose from 58 to 107. Unfortunately, in light of the patient’s poor clinical status and significant comorbidities, the patient passed away peacefully 3 weeks after hospital admission. Diaphragmatic hernia combined with pneumothorax should be differentiated from tension pneumothorax. Whether to intubate chest drainage depends on the cause of pneumothorax and pneumoperitoneum, as well as the risks and benefits of chest drainage. Additionally, mechanical ventilation should be applied cautiously, and respiratory parameters should be adjusted reasonably in patients at high risk of pneumothorax.

Introduction

Diaphragmatic hernia is usually congenital or follows thoracoabdominal injury [1,2]. Diaphragmatic hernia combined with pneumothorax is rare in the clinical setting. Pneumothorax is usually secondary to hollow viscera perforation. Some patients have a history of diaphragmatic trauma or congenital diaphragmatic herniation, while others suffer from recurrent spontaneous pneumothorax during their menstrual periods [3,4]. We present a case of pneumothorax resulting from ventilator-associated barotrauma after traumatic diaphragmatic herniation. We have learned valuable lessons from this case.

Case Description

A 67-year-old man presented to the hospital with a fever and cough for the past 20 days, with a history of chronic bronchitis, emphysema, and chronic renal failure. In daily activities, the patient could tolerate walking and had no symptoms such as chest tightness or dyspnea. The patient had a smoking history of more than 30 years but had quit smoking over 10 years ago. Additionally, the patient suffered from a traumatic diaphragmatic hernia in a car accident 26 years ago and did not receive surgical treatment. On physical examination, the breath sounds in the right lung were significantly weaker, with a few wheezes in the left lung. Chest computed tomography (CT) revealed ground-glass opacity, reticular and strip shadows, pulmonary consolidation, elevated right diaphragm, and partial atelectasis in the right lung (Fig-1). As the lung infection worsened and the oxygenation index decreased, the patient received invasive mechanical ventilation.

Fig-1

Diaphragmatic Herniation with Pneumothorax Due to Barotrauma- Lessons to Learn: A Case Report — *Chest Computed Tomography (CT) Revealed Ground-Glass Opacity, Reticular and Strip Shadows, Pulmonary Consolidation and Diaphragmatic Herniation at Admission*

Unfortunately, hypoxemia occurred on the fourth day of mechanical ventilation, with saturation of pulse oxygen (SPO₂) fluctuating between 68% and 75%. His abdomen was distended with tympany, but there was no tenderness or rebound tenderness. An urgent bedside chest and abdomen X-ray indicated pneumothorax and pneumoperitoneum equivocally (Fig-2). Taking the above into account, positive end-expiratory pressure (PEEP) was decreased from 8 cmH₂O to 5 cmH₂O, and the fraction of inspired oxygen (FiO₂) was increased to 100%. Meanwhile, spontaneous respiration was interrupted via deep sedation, strong analgesia, and muscle relaxant. Finally, SPO₂ slowly increased to 93%. The patient then received another chest and abdomen CT, which demonstrated scattered free gas in the thoracic and abdominal cavities (Fig-3).

Fig-2

Fig-3

Pneumothorax may be caused by barotrauma during mechanical ventilation. Owing to gas diffusing into the abdominal cavity via the defective diaphragm and gas being absorbed by the peritoneum, the compression on the lung and abdominal organs was significantly relieved. Finally, SPO₂ and the oxygenation index gradually rose (Table-1). Unfortunately, the patient experienced septic shock and remained unresponsive throughout the ICU stay. The patient expired peacefully 3 weeks after hospital admission.

Table-1: Arterial Blood Gas

Comparison of the Incidence of Postoperative Nausea and Vomiting between Ciprofol and Propofol in Patients Undergoing Painless Gastroscopy — *PO_2: Partial Pressure of Oxygen; PCO₂: Partial Pressure of Carbon Dioxide; SO₂: Saturation Oxygen; Fio₂: Fraction of Inspired Oxygen; P/F: Oxygenation Index*

Discussion

Diaphragmatic hernia combined with pneumothorax is very rare in clinical practice. Pneumothorax is usually secondary to hollow viscera perforation. Some patients are admitted to the hospital for tension pneumothorax, viscerothorax, and fecopneumothorax after occult traumatic diaphragmatic injury, often complicated by sepsis and poor prognosis [5-7]. Others suffer from recurrent spontaneous pneumothorax during their menstrual periods due to the rupture of ectopic endometrium over the diaphragm, resulting in diaphragmatic hernia and pneumothorax [8,9].

It is even rarer for pneumothorax to result from ventilator-associated barotrauma in a patient with a history of a traffic accident with associated traumatic diaphragmatic hernia 26 years ago. The CT also indicated diaphragmatic hernia and peripheral pulmonary bullae. The oxygen index decreased suddenly during invasive mechanical ventilation, and the X-ray showed pneumothorax and pneumoperitoneum. However, there was no tenderness or rebound tenderness, and there were numerous bullae. Therefore, we believe that the gas in the thoracic and abdominal cavities resulted from the lung via cracked bullae and diaphragmatic hernia. Compared with the previous CT, the tissue herniated into the thoracic cavity decreased after pneumothorax. We argued in a multidisciplinary discussion that chest drainage was not optimal. Interestingly, SPO₂ gradually rose the next day after pneumothorax. We might call this phenomenon “self-regulation between diaphragmatic hernia and pneumothorax.” Vermillion et al. suggested that chest drainage could relieve tension physiology in diaphragmatic hernia with fecopneumothorax [6,7], but the situation in this patient was different, and chest drainage might aggravate tension physiology.

Diaphragmatic hernia combined with tension viscerothorax should be differentiated from tension pneumothorax. Although tension pneumothorax is fatal, chest drainage may lead to catastrophic cavitary organ perforation when viscerothorax occurs [7,10]. When diaphragmatic hernia is combined with tension viscerothorax, nasogastric tube decompression could relieve compression [11]. However, it is usually difficult to insert the nasogastric tube, and in such situations, we should not repeatedly try and must be alert to the risk of cardiac arrest.

Certainly, pneumothorax in this patient also needs to be differentiated from pleural residual space. There may be pleural residual space in patients who have an old diaphragmatic hernia after abdominal contents return to the abdominal cavity while the lung is atelectatic. Nevertheless, since pneumothorax and pneumoperitoneum coexisted in this patient, we still think that pneumothorax occurred [7].

We should learn from this case that mechanical ventilation should be applied cautiously, and respiratory parameters should be adjusted reasonably in patients at high risk of pneumothorax. Once mechanical ventilation is applied, patient-ventilator synchrony should be monitored to avoid high peak airway pressure. This patient received PEEP of 14 cmH₂O to expand the lung due to extensive lung consolidation in the early treatment period, which may have promoted pneumothorax. Fortunately, pneumothorax did not lead to catastrophic consequences due to the combined diaphragmatic hernia. There are some shortcomings in this case. Considering that high PEEP may aggravate pneumothorax, we reduced PEEP to 6 cmH₂O in the later period. We should monitor transpulmonary pressure dynamically, which could inflate the lung to the maximum extent while avoiding aggravating pneumothorax.

Above all, patients with pulmonary bullae should receive a lung-protective ventilation strategy. It is important to integrate history with physical examination in the differential diagnosis of patients with simultaneous pneumothorax and pneumoperitoneum. Lastly, whether to intubate chest drainage depends on the cause of pneumothorax and pneumoperitoneum, and the risks and benefits of chest drainage.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Declaration of Conflicting Interests

The authors declare that there is no conflict of interest.

Written Informed Consent

Written informed consent was obtained from the patient’s legally authorized representative for anonymized information to be published in this article.