Spontaneous Contralateral Pneumothorax: An Unusual Cause of Respiratory Distress After Pneumonectomy

Abstract

We recently operated on a 53-year-old man who was an alcoholic and a heavy smoker with chronic bronchitis. He first presented for a left scapular indolent pain evolving for 4 months. A thorough workup revealed an apical tumor of the left lung, reaching the upper mediastinum and sheathing the left main bronchus along with subcarinal lymph nodes, that was graded IIIA. Diffuse emphysema of both lungs was also present. Cytology evidenced non–small-cell lung carcinoma. Left pneumonectomy was performed uneventfully. The patient was extubated in the operating room and transferred to the intensive care unit. His postoperative status was satisfactory except for frequent premature atrial beats present preoperatively. Four hours later, after a forceful cough, the patient developed acute respiratory distress, was lethargic, and had signs of hypoxia, hypercapnia, and distended neck and arms veins. Physical examination obviated a silent right thorax. Immediate blood gases revealed a pH of 7.15, pCO2 reaching 89 mmHg, and pO2 of 50 mmHg under high-flow oxygen mask. Bronchospasm was considered, but the patient responded poorly to bronchodilators. Entrapment of a large mucous plug was considered, and the bronchoscopy team was alerted. The surgeon, suspecting right mediastinal shift, declamped the left thoracic tubes with no result. Deteriorating drastically, the patient was intubated. An urgent chest x-ray revealed a right-sided tension pneumothorax shifting the mediastinum leftward. A right chest tube was inserted. The patient was immediately relieved and extubated 20 minutes later. Because of persistent air leakage under suction, a right pleural decortication was performed 72 hours later with excision of three apical emphysematous bullae. Causes of acute respiratory distress after pneumonectomy are numerous including the following: atelectasis, mediastinal shift, mucous plug, postpneumonectomy pulmonary edema, cardiac torsion, disrupted bronchus, and bronchospasm.1Higgins T.L. Postthoracotomy complications.in: Kaplan J.A. Slinger P.D. Thoracic Anesthesia. (ed 3). Churchill Livingstone, Philadelphia, PA2003: 388Google Scholar Spontaneous contralateral pneumothorax after pneumonectomy, to our knowledge, has never been reported in the English literature. A thorough review of the literature revealed, surprisingly, one single article reporting this entity.2Besa G. Zanotelli F. Perusi O. et al.[Controlateral spontaneous pneumothorax after pneumonectomy].Fracastoro. 1965; 58: 419-426PubMed Google Scholar Nonetheless, we believe that this entity could be more frequently encountered in clinical practice and is being somehow underreported. In conclusion, a spontaneous contralateral pneumothorax, although very unusual, may be a cause of acute respiratory distress after pneumonectomy. It should be urgently diagnosed and treated to prevent potentially lethal complications.