Introduction:
Pulmonary air embolism is an uncommon type of pulmonary embolism and is mainly due to medical or surgical procedures [1]. Pulmonary air embolism can occur due to direct entry of air into the vasculature [2] or due to an increase in the pressure gradient between the atmosphere and the vasculature which most commonly occurs in the setting of neurosurgical operations where patients are operated on in a sitting position [2,3]. Central venous catheter insertion or removal related pulmonary air embolism is an under-diagnosed iatrogenic morbidity and can pose significant morbidity and mortality [4,6]. The outcome associated with air embolism is related to the rapidity of air entry to the vasculature, the amount of air entered, and the volume. In dogs, for example, it was estimated that the fatal dose of air when injected rapidly was 7.5 ml/kg [2] but, in humans, it is not yet known but a volume of 100-300 ml can be lethal [2,7]. The diagnosis needs a clinical suspicion and transthoracic echocardiography is usually the first test to be done, though can miss mild cases in which case transesophageal echocardiography can be diagnostic [8]. Management of patients with air embolism begins with stabilizing the airway, breathing, and circulation while simultaneously diagnostics are getting done. The most definitive treatment is the removal of air bubbles from the right ventricle through a pulmonary venous catheter or the use of hyperbaric oxygen which reduces the volume of air by inducing systemic hyperoxia displacing the nitrogen from the air bubbles into the blood and reducing its sizes thereby minimizing the obstructive effect of the air in the vasculature [9,10].
The mortality rate has been decreasing with the more frequent use of hyperbaric Oxygen to manage these patients as well as for the long-term complications [5]. We present a 27 years old pleasant male who was admitted for a suspected demyelinating disease and received pulse steroid and followed by 7 sessions of plasma exchange through a right central venous catheter and after removal of the catheter the patient developed sudden severe difficulty breathing with hypoxia, air embolism was suspected and bedside echocardiography demonstrated numerous air bubbles in the left ventricle and left atrium due to right to left shunt, probably a patent foramen ovale. The patient was then shifted to the intensive care unit and received hyperbaric oxygen and showed significant improvement without any neurological or cardiac sequelae.