Tension pneumothorax after lateral decubitus positioning for single lung transplant

BACKGROUND: Tension pneumothorax is a clinical emergency that can develop quickly under general anesthesia especially in the patient who has end stage lung disease undergoing lung transplantation when placed in the lateral decubitus position. Patients with emphysematous blebs on their lungs are at increased risk of pneumothorax when positive pressure ventilation is administered either through a mask or endotracheal tube. METHODS: We describe a case of ipsilateral tension pneumothorax with hemodynamic instability after lateral positioning during single lung transplantation. RESULTS: Lateral positioning of a patient can potentially accelerate the conversion of simple pneumothorax into a tension pneumothorax due to a significant increase of the functional residual capacity in the nondependent lung. CONCLUSIONS: Rapid diagnosis and treatment is essential as it can lead to intraoperative hemodynamic instability and cardiac arrest. Therefore, tension pneumothorax should be high on the differential when a patient develops hemodynamic instability shortly after repositioning from a supine to lateral decubitus position. Diagnosis may be made quickly in the operating room with lung ultrasound but not with transesophageal echocardiography due to shift of the mediastinum.