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• W2090133725 abstract "Communications for this section will be published as space and priorities permit. The comments should not exceed 350 words in length, with a maximum of five references; one figure or table can be printed. Exceptions may occur under particular circumstances. Contributions may include comments on articles published in this periodical, or they may be reports of unique educational character. Specific permission to publish should be cited in a covering letter or appended as a postscript. To the Editor: In “A New Treatment Modality for Pneumoperitoneum Associated with Mechanical Ventilation” (Chest 1982; 81:519–20) Drs. Stein and Lane describe a case of pneumoperitoneum as a complication of mechanical ventilation and an ingenious way of treating it by inserting a peritoneal (Tenckhoff) catheter which was connected to chest-tube drainage. The treatment was successful, thus permitting weaning of the patient from the respirator. However, it is not clear whether the pneumoperitoneum was an isolated barotrauma complication from the mechanical ventilation or whether it was in association with or even preceded by an undiagnosed pneumothorax. The right pneumothorax which was diagnosed after exploratory laparotomy for free air in the peritoneal cavity, could have been present before the occurrence of pneumoperitoneum and difficult to see on a portable chest film. Other published cases of pneumoperitoneum associated with mechanical ventilation were all associated with either pneumothorax or with pneumomediastinum or both, and usually these complications preceded the development of pneumoperitoneum.1Turner WW Fry WJ. Pneumoperitoneum complicating mechanical ventilator therapy.Arch Surg. 1977; 112: 723-726Crossref PubMed Scopus (20) Google Scholar, 2Glauser FL Bartlett RH. Pneumoperitoneum in association with pneumothorax.Chest. 1974; 66: 536-540Crossref PubMed Scopus (50) Google Scholar, 3Hillman KM. Pneumoperitoneum—a review.Crit Care Med. 1982; 10: 476-481Crossref PubMed Scopus (70) Google Scholar This fact suggests that pneumoperitoneum, as an isolated complication from mechanical ventilation, is rare. High tidal volume (18–22 ml per kg body weight) combined with high PEEP (over 15 cm H2O) were considered to be causative factors for barotrauma.4Bone RC Francis PB Pierce AK. Pulmonary barotrauma complicating positive end-expiratory pressure.Am Rev Respir Dis. 1975; 111: 921Google Scholar The marked and prolonged air drainage after insertion of the Tenckhoff catheter (seven weeks) presumes a rather large communication between airways and peritoneal cavity, a fact which would raise the question of the likelihood of the coexistence of other barotrauma complications along with pneumoperitoneum, namely pneumothorax. A decubitus or cross-table chest film would have reliably ruled out or confirmed a pneumothorax. The diagnosis of pneumothorax on a portable chest film, particularly small or medium-size pneumothorax, is not always easy to make. It has been postulated5Moskovitz PS Griscom NT. The medial pneumothorax.Radiology. 1976; 120: 143-147Crossref PubMed Scopus (32) Google Scholar that in the supine patient the collapsed lung falls against the posterior chest wall and air in the pleural space accumulates anteriorly (Fig 1). Therefore, the classic picture of a pneumothorax which one can see on a PA upright chest film, namely air lateral to or above the displaced lung,5Moskovitz PS Griscom NT. The medial pneumothorax.Radiology. 1976; 120: 143-147Crossref PubMed Scopus (32) Google Scholar is not usually present on a portable supine chest film until the pneumothorax becomes large (Fig 1). A relative hyperlucency of the right or left upper quadrant, visualization of the anterior costophrenic angle, and a hyperlucency between the medial aspect of the lung and the anterior mediastinum are specific radiologic signs of a pneumothorax on a supine chest film.5Moskovitz PS Griscom NT. The medial pneumothorax.Radiology. 1976; 120: 143-147Crossref PubMed Scopus (32) Google Scholar,6Rhea JT van Sonnenberg E McLoud TC. Basilar pneumothorax in the supine adult.Radiology. 1979; 133: 593-595Crossref PubMed Scopus (48) Google Scholar A posteriorly placed chest tube might not decompress the anteromedial component of the pneumothorax and this may require an anterior tube (Fig 1). Decubitus or cross-table films by visualization of the visceral pleura confirm the diagnosis of pneumothorax in doubtful situations.5Moskovitz PS Griscom NT. The medial pneumothorax.Radiology. 1976; 120: 143-147Crossref PubMed Scopus (32) Google Scholar,6Rhea JT van Sonnenberg E McLoud TC. Basilar pneumothorax in the supine adult.Radiology. 1979; 133: 593-595Crossref PubMed Scopus (48) Google Scholar If the patient described had pneumothorax associated with her pneumoperitoneum, then a well placed chest tube, at the proper time, would efficiently have resolved both the pneumothorax and the pneumoperitoneum and probably in a shorter time, thus eliminating the need to resort to more unusual solutions such as insertion of an abdominal catheter to drain the air out." @default.
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• W2090133725 title "A New Treatment Modality for Pneumoperitoneum Associated with Mechanical Ventilation" @default.
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