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.