Management of Sudden Post-Operative Lung Collapse in Austere Environment: A case report

We describe the management of a patient who sustained fragment injuries from a motor shelling blast, presenting to a field surgical hospital 12 hours later, with an isolated acute abdomen. Plain radiographs showed small fragments in the chest and abdomen, without pneumothorax or haemothorax. Laparotomy revealed an isolated cortical laceration of the lower pole of the right kidney with a peri-nephric hematoma. The hematoma was evacuated and a drain inserted. On the second post-operative day he developed respiratory distress, peripheral oxygen desaturation and reduced breath sounds on the right lung field. A plain film revealed complete opacity of the right lung field with tracheal shift to the right. A diagnosis of right lung collapse was made. Due to the presence of small fragments in the chest, the possibility of a haemothorax was considered. A right chest drain was inserted which drained nothing. A control film on table confirmed proper placement of the tube with collapsed right lung. The patient continued to de-saturate at 88%. Due to lack of a bronchoscope, tracheostomy was done under local anaesthesia to facilitate a good and strong cough reflex, followed by bronchial suction and lavage. Thick mucus plug was extracted, saline lavage done by instilling 10ml into the tracheostomy and suction, with good cough reflex from the patient. This was followed by a dramatic improvement in peripheral oxygen saturation to above 95%. Immediate control plain radiographs on table revealed a well expanded lung and the patient made an un-eventful recovery. Subsequent chest films showed complete resolution of the lung pathology.