European Journal of Anaesthesiology 1999, 16, 259–262 CASE REPORT Ruptured hemidiaphragm after bilateral lung transplantation J. Go ´ mez-Arnau‡, N. Novoa*, M. G. Isidro†, A. Plaza, F. Galindo and C. Ezquerro Servicios de Anestesiologı ´a-Reanimacio ´ n, *Cirugı ´a Tora ´ cica, †Radiologia, Hospital Puerta de Hierro, San Martı ´n de Porres, 4, 28035 Madrid, Spain Summary aetiology and suggest that the direct cause could be an increase in intra-abdominal pressure during chest A case of right hemidiaphragm rupture and abdominal physiotherapy. herniation into the thorax occurring during the immediate post-operative course of double-lung Keywords: : rupture;  - transplantation is reported. This complication has not : post-operative. been reported previously. We examine the possible Introduction symptoms, unless there is herniation and in- carceration of abdominal viscera within the dia- Diaphragmatic rupture is a relatively uncommon path- phragm. ology that occurs mainly after major blunt or pen- We report a case of right hemidiaphragmatic rupture etrating trauma [1,2]. Spontaneous rupture, on the occurring in a double-lung transplant patient after other hand, is a very rare event that has been reported chest physiotherapy on the fourth post-operative day. anecdotally in relation to activities such as dancing [3], To our knowledge, this lesion has not been described normal delivery [4], coughing [5] and sudden intense previously in such a setting. exercise. While it appears that the mechanisms of traumatic and spontaneous rupture may differ, both would have to involve a sudden increase in intra- Case report abdominal pressure producing the herniation of ab- A 46-year-old man was scheduled for lung trans- dominal contents into the thorax. plantation to treat emphysema. He had presented with The rupture of the diaphragm may be detected dyspnoea and expectoration 6 years earlier and was immediately after injury on arrival of the patient at referred to our hospital with a diagnosis of chronic the hospital or some time later during initial hospital obstructive pulmonary disease; treatment consisted admission. Late presentation or delayed onset of of oxygen, bronchodilators and corticosteroids. His hernia [6] may occur at any time after trauma [1]. medial history included a thoracoabdominal blunt Whereas the diagnosis of traumatic rupture can be trauma when he was 15 years old (he had been run facilitated by the high index of suspicion, delayed or over), which did not require treatment. He led a normal late presentation and spontaneous rupture can easily life and played sports (soccer) regularly. be overlooked because of the vague nature of the His preoperative laboratory results were normal ex- cept for a Pa 2 and Pa 2 of 9.2 KPa and 5.9 KPa, Accepted September 1998 respectively, while breathing oxygen. Respiratory ‡ Present address: Department of Anaesthesiology and function tests revealed a FCV of 38% and FEV1 of Critical Care, Fundacio ´ n Hospital Alcorco ´ n, Madrid. 13%; cardiac preparatory investigation showed right Correspondence: J. Go ´ mez-Arnau, Puerto Rico, 5, 28220 Majadahonda, Madrid, Spain. ventricular dilation with an ejection fraction of 0.36.  1999 European Academy of Anaesthesiology 259