Lateral decubitus position for life-threatening postpneumonectomy pulmonary edema

Abstract

Sir: Postpneumonectomy pulmonary edema (PPE) has an incidence of 2.5–13.5%, with an overall mortality of 50%–100% [1, 2, 3, 4]. There is no specific treatment for PPE. We describe three consecutive cases of life-threatening hypoxemia occurring during PPE successfully managed with lateral decubitus (LD), with the remaining lung placed uppermost. The ventilatory and hemodynamic parameters of these three patients are reported in Table 1. A 54-year-old man underwent left pneumonectomy for squamous cell carcinoma. He experienced progressive respiratory deterioration and was intubated on postoperative day 3 and transferred to the intensive care unit (ICU). The patient was sedated and paralyzed. Chest X-ray showed a massive alveolar infiltration. Transthoracic echocardiography revealed a severe right ventricular dysfunction with a systolic pulmonary artery pressure (PAPS) of 65 mmHg and a left ejection fraction of 70%. Nine hours after admission, the patient was placed on LD. Pulse oximetry improved in the following minutes. Except for nursing care, the patient was left on LD up to day 7, when the supine position was progressively introduced. He was extubated at day 10 and had an uneventful recovery. A 63-year-old man underwent left pneumonectomy for squamous cell carcinoma. He became dyspneic and was intubated on postoperative day 6, sedated and paralyzed. Upon admission to the ICU, transthoracic echocardiography revealed a PAPS of 47mmHg, with right ventricular enlargement and a left ejection fraction of 57%. Fourteen hours after admission, chest X-ray showed persistent massive diffuse alveolar infiltration. The patient was then placed on LD. Pulse oximetry saturation rapidly increased. On day 11 the supine position was progressively re-introduced. He was extubated at day 14 and had an uneventful recovery. A 51-year-oldman with an alcohol habit underwent right pneumonectomy for adenocarcinoma. He had a progressive respiratory deterioration, was intubated on day 3, sedated