Sir,

We are presenting a case of bilateral pneumothorax with pneumomediastinum in a 48 hours old infant, posted for emergency repair of high anorectal malformation under general anaesthesia. Preoperatively there is decrease in air entry on left lung and no evidence of pneumothorax. Room air saturation was 90 to 92 %. After intubation, saturation maintained, 95% to 98% with 100% O₂. After 30 minutes of intubation there is acute decrease in saturation to 60%, bag was tight, and impossible to ventilate, followed by bradycardia and arrest. CPR started and baby resuscitated. We suspect barotrauma causing pneumothorax. Bilateral ICD was inserted and CXR taken, showing bilateral pneumothorax and pneumomediastinum. Saturation gradually improved to 100% with 40% FIO2. Child was extubated and CT scan thorax was planned which revealed rupture emphysematous bulla. We want to highlights here that any congenital anomalies, as ano-rectal malformation in this case may associated with multiple other defect. Chest x-ray may not reveal the diagnosis of emphysematous bulla. Intubation and IPPV may cause rupture of bullae and can leads to pneumothorax. So it is better to do complete investigation .which should include CT of whole body and particularly chest to rule out undiagnosed bulla in lung.

Figure 1

Figure 1 (Bilateral Pneumothorax with Pneumomediastinum)