Failure to meet extubation criteria in the setting of suspected buffalo chest physiology

We report the case of a patient who failed to meet tracheal extubation criteria due to low tidal volumes from suspected buffalo chest, which is a single pleural space physiology. This presentation followed the resection of a large pleural mass in a 59-year-old woman with a history of exercise-induced asthma, hypertension and tumour-related chronic respiratory failure. Creation of a pleuro-pleural communication during the resection of this large, unilateral pleural mass led to bilateral pneumothoraces and contributed to patients inability to generate negative inspiratory force leading to failure to meet extubation criteria. Buffalo chest may be more prevalent than suspected and should be a differential diagnosis for low tidal volumes with spontaneous ventilation following thoracic surgery. It can be differentiated from other causes of decreased tidal volume using clinical examination, ultrasound and radiography. Bilateral chest tube placement can be considered to expedite pneumothorax resolution and tracheal extubation.