In Reply:—

We thank Drs. Dorje and Cueto for their interest in our recent publication. 1Dr. Dorje has focused on the possibility that a tension pneumothorax may have been unrecognized and has offered suggestions as to how the diagnosis could have been made more expeditiously. In response, one of the initial resuscitative measures performed during the described event was to place angiocatheters in bilateral second intercostal spaces of the anterior chest wall because of the clinical suspicion of a tension pneumothorax. Because this resulted in only partial improvement of the patient’s clinical signs, the transesophageal echocardiographic (TEE) examination was performed to determine the possibility of cardiac tamponade, pulmonary embolus, or acute myocardial infarction. As our surgical team prepared for chest tube placement, the initial TEE examination of the heart was already being performed. We understand that other institutions may not have TEE readily available. However, our operating rooms have immediate availability of TEE and fiberoptic bronchoscopy as well as exceptional technical support; thus, acquiring these instruments in our institution is accomplished in minutes. In addition, a tension pneumothorax would be identifiable by the surgeon during the operation only if the diaphragm is in direct view. If the surgeons were operating in the lesser sac, debriding necrotic pancreas, and the patient had a narrow-angled costal margin, a tension pneumothorax may be difficult to appreciate. Nevertheless, the purpose of our case report was not to discuss the management of tension pneumothorax, which may be found in numerous anesthesia, surgical, and medical textbooks, but to illustrate the interesting finding of systemic air embolism associated with barotrauma documented by TEE, which had not been described previously.

Ibrahim AE, Stanwood PL, Freund PR: Pneumothorax and systemic air embolism during positive-pressure ventilation. A NESTHESIOLOGY 1999; 90:1479–81