Po Pien-Lung, Bai Hsueh-Fen, Lin Chia-Heng, Lin Chen-Chun
Division of Chest Medicine, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan, ROC.
Fu-Jen Catholic University School of Medicine, Taipei, Taiwan, ROC.
Respir Med Case Rep. 2021 Jan 7;32:101341. doi: 10.1016/j.rmcr.2021.101341. eCollection 2021.
Pneumomediastinum is an abnormal accumulation of air within the mediastinum. Herein, we report a rare case in which a patient initially developed pneumomediastinum and extensive subcutaneous emphysema after bronchoscopic bronchioloalveolar lavage (BAL). The condition then progressed to abdominal compartment syndrome leading to death.
An 80-year-old man with acute respiratory failure caused by severe pneumonia and septic shock, was admitted to our intensive care unit. Bronchoscopic BAL was performed for microbiological specimen collection. The patient developed subcutaneous emphysema after the procedure, and pneumomediastinum was identified on subsequent chest radiography. The patient initially received supportive care. However, he experienced persistent hypotension, which did not respond to vigorous fluid replacement and high dose vasopressor treatment. Physical examination revealed distended, tense abdomen with diffuse tympanic sound upon percussion. Computer tomography scan showed extensive subcutaneous emphysema, massive air accumulation in the retroperitoneal cavity, near total collapse of the inferior vena cava, and left sided shifting of intra-abdominal organs. The impression was tension pneumoperitoneum with abdominal compartment syndrome. The patient eventually died of refractory hypotension.
Iatrogenic injury is a rare condition. The common complications include hypoxia, bleeding, infection, arrhythmia, subcutaneous emphysema, and pneumomediastinum, and these can be managed conservatively. However, more complex and life-threatening conditions can be caused by tracheal perforation or alveolar rupture, and can lead to pneumothorax, pneumoperitoneum, or even abdominal compartment syndrome. A high level of suspicion is needed for early detection, and immediate decompression is required to prevent death.
纵隔气肿是纵隔内空气的异常积聚。在此，我们报告一例罕见病例，一名患者在支气管镜下进行细支气管肺泡灌洗（BAL）后最初出现纵隔气肿和广泛的皮下气肿。随后病情进展为腹腔间隔室综合征并导致死亡。
一名80岁男性因严重肺炎和感染性休克导致急性呼吸衰竭，入住我们的重症监护病房。为采集微生物标本进行了支气管镜BAL。术后患者出现皮下气肿，随后胸部X线检查发现纵隔气肿。患者最初接受了支持治疗。然而，他持续低血压，积极补液和高剂量血管升压药治疗均无效。体格检查发现腹部膨隆、紧张，叩诊呈弥漫性鼓音。计算机断层扫描显示广泛的皮下气肿、腹膜后腔大量积气、下腔静脉几乎完全塌陷以及腹腔内器官向左移位。诊断为张力性气腹伴腹腔间隔室综合征。患者最终死于难治性低血压。
医源性损伤是一种罕见情况。常见并发症包括缺氧、出血、感染、心律失常、皮下气肿和纵隔气肿，这些可通过保守治疗处理。然而，气管穿孔或肺泡破裂可导致更复杂且危及生命的情况，可导致气胸、气腹，甚至腹腔间隔室综合征。需要高度怀疑以早期发现，并需要立即减压以防止死亡。
