POSTLOBECTOMY PULMONARY EDEMA: A RARE BUT LETHAL COMPLICATION

Abstract

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Post-lobectomy pulmonary edema is a fairly rare, but disastrous complication carrying a very high mortality rate. Given that this complication can present in patients with no prior evidence of cardiac disease, without evidence of systemic volume overload and with non-specific findings on early chest imaging, clinicians must have a low-threshold for suspicion as delayed treatment is often fatal. CASE PRESENTATION: A 63 year-old male with type 1 diabetes mellitus, hypertension, chronic kidney disease stage III and right lung adenocarcinoma admitted for a right lower lobectomy. For the first 2 days post-op, patient required non-rebreather mask for mild, intermittent desaturations with chest XR demonstrating small right pleural effusion and small right pneumothorax with atelectasis. On post-operative day 3, developed persistent hypoxia requiring continuous BiPAP and transfer to ICU. Chest x-ray at that time demonstrated a new non-specific left mid-lung opacification and patient was started on antibiotic coverage. Over the following 24 hours, serial chest imaging demonstrated evolution of left pulmonary opacification to involve entire lung consistent with acute lung injury/pulmonary edema. Patient was started on a furosemide infusion and discontinuation of antibiotics followed by transition to scheduled IV furosemide. Patient experienced clinical improvement, was successfully weaned off oxygen and repeat imaging demonstrated significant improvement in bilateral lung fields. DISCUSSION: Surgical resection continues to be the gold-standard for definitive treatment of non-metastatic non-small cell lung cancer and several retrospective studies have described the incidence, morbidity, and mortality of post-procedure pulmonary edema. The incidence ranges from 1-7% after lobectomy with a mortality rate ranging from 50-100%. The etiology is likely multifactorial, including oxidative damage from ischemia-reperfusion, over-zealous intra- and post-operative fluid administration and disrupted lymphatic drainage. The contra-lateral lung is also often exposed to hyperoxia, volutrauma and hyperinflation as ventilation is directed away from the region in which the lobectomy or pneumonectomy is being performed resulting in endothelial damage. Our patient was fortunate to have serial imaging performed which demonstrated the progression of his pulmonary edema allowing for prompt adjustments being made to his therapy. CONCLUSIONS: As patients do not follow a uniform course and pulmonary edema has been documented occurring anywhere from the first 12 hours to as late as 7 days post-op, diagnosis of post-lobectomy pulmonary edema can often be difficult as patient’s may not have any other clinical signs of volume overload. This is complicated by early imaging often demonstrating non-specific changes which may lead clinicians to other conclusions (eg. infection) which may delay proper treatment. Reference #1: Jordan, S., Mitchell, J. a, Quinlan, G. J., Goldstraw, P., & Evans, T. W. (2000). The pathogenesis of lung injury following pulmonary resection. The European Respiratory Journal, 15(4), 790–799. Reference #2: Villeneuve, P. J., & Sundaresan, S. (2006). Complications of Pulmonary Resection: Postpneumonectomy Pulmonary Edema and Postpneumonectomy Syndrome. Thoracic Surgery Clinics. Reference #3: Cook, D., Powell, E., & Gao-Smith, F. (2007). Post-pneumonectomy pulmonary edema. In Yearbook of Intensive Care and Emergency Medicine 2009 (pp. 473–482). DISCLOSURES: No relevant relationships by Erika Faircloth, source=Web Response No relevant relationships by Deep Phachu, source=Web Response