Kim Jiyoung, Kim Jeong-Hee, Kwon Hyeokjae
Department of Nursing, Woosuk University, Wanju-gun, Jeonbuk, South Korea.
Department of Plastic and Reconstructive Surgery, College of Medicine, Chungnam National University, Daejeon, South Korea.
Medicine (Baltimore). 2025 Jul 18;104(29):e43410. doi: 10.1097/MD.0000000000043410.
Oxygen therapy is a critical component of postoperative care, particularly after general anesthesia. Although generally safe, its improper administration can lead to serious complications. This report details an incident of lung overinflation during postoperative oxygen therapy that resulted in pneumothorax and pneumoperitoneum.
A 63-year-old female patient with tracheostomy underwent pressure sore reconstruction under general anesthesia. Postoperatively, the patient was transferred to the recovery room, and oxygen therapy was initiated. During oxygen administration, the anesthesiology nurse omitted the connection of a heat-moisture exchanger and thereby inadvertently administered excessive dry positive pressure ventilation. Subsequently, the patient developed acute respiratory distress.
Clinical examination revealed decreased bilateral breathing sounds and abdominal distension. Computed tomography confirmed bilateral pneumothorax and pneumoperitoneum.
Conservative management was chosen.
The patient's condition stabilized, and she was discharged after 3 weeks with no long-term complications.
This case highlights the importance of careful monitoring and adherence to appropriate techniques during postoperative oxygen therapy. Overinflation of the lungs can lead to life-threatening conditions such as pneumothorax and pneumoperitoneum. This incident highlights the need for rigorous training and vigilance among healthcare professionals to prevent such occurrences. Although oxygen therapy is essential for patients recovering from general anesthesia, this case illustrates the potential risks associated with improper administration. Awareness and preventive measures are crucial for avoiding similar adverse events and ensuring patient safety and optimal outcomes.
氧疗是术后护理的关键组成部分，尤其是在全身麻醉后。虽然通常是安全的，但不当使用可能会导致严重并发症。本报告详细介绍了一例术后氧疗期间肺过度充气导致气胸和气腹的事件。
一名63岁行气管切开术的女性患者在全身麻醉下接受了压疮重建手术。术后，患者被转入恢复室并开始氧疗。在给氧过程中，麻醉护士遗漏了热湿交换器的连接，从而无意中给予了过多的干燥正压通气。随后，患者出现急性呼吸窘迫。
临床检查发现双侧呼吸音减弱和腹胀。计算机断层扫描证实双侧气胸和气腹。
选择保守治疗。
患者病情稳定，3周后出院，无长期并发症。
该病例强调了术后氧疗期间仔细监测和遵循适当技术的重要性。肺过度充气可导致危及生命的情况，如气胸和气腹。这一事件凸显了医疗保健专业人员进行严格培训和保持警惕以防止此类事件发生的必要性。虽然氧疗对全身麻醉后恢复的患者至关重要，但该病例说明了不当使用相关的潜在风险。提高认识和采取预防措施对于避免类似不良事件以及确保患者安全和最佳预后至关重要。
