Bilateral Lobar Lung Transplantation after Smoke Inhalation Injury - A Case Report

Abstract

Introduction Pulmonary fibrosis due to smoke inhalation injury has to our best knowledge previously not been reported as an indication for lung transplantation (LTx). For small adult and pediatric recipients, lobar LTx can be an option to solve the issue with size mismatch with donors. Case Report A 41-year old woman developed pulmonary fibrosis due to smoke inhalation injury after a suicide attempt in 2013. After long term careful psychiatric evaluation, the patient was listed for LTx in 2017. Due to her short stature of 145 centimetres and underweight (BMI 16), finding matching organs was difficult. Her condition slowly deteriorated and early 2020, veno-arterial extracorporeal membrane oxygenation (vaECMO) was initiated. After eight days on vaECMO she was lung transplanted with bilateral lower lobes. By then she was severly underweight (BMI 14). The postoperative period was complicated with haemorrhage and severe respiratory failure. The patient developed multiple organ failure and an iatrogenic esophageal perforation was discovered. It initially measured 2 × 1 centimetres, increased to a maximum of 7 × 1 centimetres and was treated with endoluminal vacuum therapy (VAC). The foam sponge was replaced every three days, and after 2 months only a fibrin-coated surface remained and VAC was discontinued. Weaning from mechanical ventilation was not possible until after 4 months, which in part was caused by the treatment of the perforation. The patient was discharged with nutritional and respiratory support after 6 months in hospital. At a follow up visit 2 months later she was in good health, mentally stable and required neither non-invasive ventilation nor percutaneous endoscopic gastrostomy for nutrition. Summary This case report highlights a rare - if not unique - etiology of chronic respiratory failure leading to lung transplantation. Iatrogenic esophageal perforation occurred post LTx, previously always requiring major surgery, now treated successfully with VAC. Despite challenges both pre and post transplantation, the outcome was eventually successful.