# Urgent Use of Sugammadex in a Patient With Occult Bronchopleural Fistula Manifested Following Anesthesia Induction

## TL;DR

A patient with a hidden chest wall air leak was successfully managed using sugammadex to reverse muscle relaxation during anesthesia.

## Contribution

This case highlights the urgent, non-critical use of sugammadex in managing anesthesia for a patient with an occult bronchopleural fistula.

## Key findings

- Sugammadex reversed rocuronium effects, enabling spontaneous breathing in a patient with a massive air leak.
- High-flow oxygen-air insufflation helped maintain oxygenation during mechanical ventilation failure.
- The case demonstrates a novel approach to managing anesthesia in patients with occult bronchopleural fistulas.

## Abstract

Sugammadex could play a significant role in managing the “cannot intubate, cannot ventilate” scenarios. However, the urgent use of sugammadex in intubated patients after induction of anesthesia is uncommon. We report the case of an 85-year-old, 45 kg man with a history of pulmonary resection for lung cancer and open window thoracostomy for postoperative pyothorax. He underwent a ureteral stent exchange for ureteral calculi. During anesthesia induction, 40 mg of rocuronium was administered, followed by uneventful mask ventilation and tracheal intubation. Subsequent mechanical ventilation failed due to massive air leakage from an occult bronchopleural fistula in the left chest wall that manifested following anesthesia induction. However, oxygenation was maintained with oxygen-air insufflation from the anesthesia machine by closing the adjustable pressure-limiting valve and maximizing fresh gas flow. Although the tracheal tube was blindly advanced with the intention of one-lung ventilation via the right lung, it was unsuccessful. Subsequently, 200 mg of sugammadex was administered to reverse the rocuronium effect, allowing the continuation of anesthesia with desflurane under spontaneous breathing. High-flow oxygen-air insufflation via a tracheal tube and urgent, but not critical, use of sugammadex to restore spontaneous breathing were helpful for the anesthetic management of this patient who developed a massive air leak due to an occult bronchopleural fistula that manifested following anesthesia induction.