Emergency Pneumonectomy Research Articles

Pulmonary artery resection with autologous pericardial conduit to avoid pneumonectomy in lung neoplasms surgery: How to do it

Pulmonary artery resection with autologous pericardial conduit to avoid pneumonectomy in lung neoplasms surgery: How to do it

Management of bronchopleural fistula using Amplatzer duct occluder device.

Management of bronchopleural fistula using Amplatzer duct occluder device.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Posttraumatic pneumonectomy and management of severely contaminated pleural space.

Multidisciplinary Management of Lung Destruction Presenting with Massive Hemoptysis and Asphyxia

Lung destruction with massive hemoptysis is a life-threatening condition associated with a poor prognosis in the absence of prompt management. Asphyxia due to the flooding of the airways rather than exsanguination is usually the cause of death, so the initial treatment is resuscitation and protecting the airway. Prompt identification of its causes and location is mandatory to do an adequate treatment and to avoid fatal complications. We describe the case of a patient who was an emergency admission with large volume hemoptysis and asphyxia. After lung destruction was confirmed the cause of massive hemoptysis by a chest computed tomography (CT)，She underwent bronchial artery embolization (BAE) and controlled the bleeding. But due to recurrent bleeding two days later, she performed pneumonectomy and achieved hemostasis. BAE is now considered as first-line therapy or may be used as a tool to stabilize the patient before surgery. Emergency pneumonectomy is indicated for lung destruction with recurrent hemoptysis not controlled by embolization and is generally considered a last resort.

Emergency pneumonectomy: a life-saving measure for severe recurrent hemoptysis in tuberculosis cavitary lesion.

Hemoptysis constitutes a common and urgent medical problem. Swift and effective management is of crucial importance, especially in severe, life-threatening cases. Because of bronchial artery or a branch of pulmonary artery erosion due to cavitary infiltration, bronchiectasis, fungus ball, broncholithiasis, or destroyed lung, the bleeding can lead to highly compromised gas exchange or sometimes can be a life-threatening situation. Chest computerized tomography and bronchoscopy remain the methods of choice for lateralization of the disease. Some patients can be treated successfully with endobronchial interventions. Bronchial artery embolization can be rewarding in some patients but the recurrence rate is higher in tuberculosis than other etiologies of hemoptysis. Surgical resection of the lung, mainly lobectomy, remains a life-saving procedure but it should be performed very selectively to avoid higher postoperative morbidity and mortality.

Emergent pneumonectomy for lung gangrene – does the outcome warrant the procedure?

Emergent pneumonectomy for lung gangrene – does the outcome warrant the procedure?

Emergent Pneumonectomy for Lung Gangrene: Does the Outcome Warrant the Procedure?

Sloughing and gangrene of a complete lung are only very infrequently encountered complications of necrotizing pneumonia and fulminant pulmonary abscess formation. Thus far the role of emergent pneumonectomy is not established. The outcome of patients who underwent anatomic lung resection for lung gangrene at 3 centers for thoracic surgery during the last 13 years was retrospectively analyzed. Only cases of necrotizing pneumonia were included whereas malignant lesions were excluded. Overall 44 patients were indentified (average age 56.3 years). Pulmonary sepsis (27 of 44), pleural empyema (29 of 44), persistent air leakage (14 of 44), and respiratory failure with mechanical ventilation (14 of 44) were present preoperatively. The mean Charlson comorbidity index was 2.77. Procedures were segmentectomy (7), lobectomy (26), and pneumonectomy (11). In-hospital mortality was 7 of 44; 2 following pneumonectomy and 5 after lobectomy. In comparing the pneumonectomy group with the lobectomy group we found no significant differences in age (p=0.59), Charlson comorbidity index (p=0.18), and postoperative mortality (p=1). Charlson comorbidity index 3 or greater (odds ratio [OR], 8.41; 95% confidence interval [CI], 0.88 to 421.71; p=0.04), preoperative pleural empyema (OR, 3.56; 95% CI, 0.37 to 179.62; p=0.39) and preoperative persistent air leak (OR, 7.34; 95% CI, 1.00 to 89.98; p=0.02) were associated with higher risk for fatal outcome. Furthermore, patients with sepsis (p=0.03) and patients sustaining acute renal failure (p=0.04) had significantly higher mortality. Pulmonary sepsis and its complications as well as preexisting comorbidity are the major reasons for fatal outcome, whereas the extent of surgical resection shows no significant influence. Emergent pneumonectomy as ultimate ratio is not only justified but also life saving. Further improvement seems achievable by earlier surgical intervention before the onset of pulmonary sepsis.

Outcomes after pneumonectomy for benign disease: the impact of urgent resection.

Pneumonectomy for benign disease is often complicated by inflammatory processes that obscure operative planes. We reviewed our experience to evaluate the impact of requiring urgent or emergent pneumonectomy on outcomes. All pneumonectomies for benign conditions from 1997 to 2012 at a single institution were retrospectively reviewed. Mortality was assessed using multivariable logistic regression that included laterality, age, and surgery status, which was emergent if performed within 24 hours of initial evaluation, urgent if performed after 24 hours but within the same hospital stay, and otherwise elective. Among 42 pneumonectomies, completion pneumonectomy after previous ipsilateral lung resection was performed in 14 patients (33%). Resection was elective in 22 patients (52%), urgent in 12 (28%), and emergent in 8 (19%). The most common indication was for necrotic lung (n= 12; 29%). Muscle flaps were used in 26 patients (62%). Perioperative mortality for the entire cohort was 29% (n= 12) and was significantly higher when surgery was urgent (5 of 12; 42%) or emergent (5 of 8; 62.5%) compared with elective (2 of 22; 9.1%) (p= 0.03). Requiring urgent or emergent surgery remained a significant predictor of mortality in multivariable analysis (odds ratio 10.4, p= 0.01). Pneumonectomy for benign disease has significant risk for mortality, particularly when not performed electively. Although surgery cannot be planned in the setting of trauma or some situations of acute infection, patients known to have conditions that are likely to require pneumonectomy should be considered for surgery earlier in their disease course, before developing an acute problem that requires urgent or emergent resection.

Intensive care unit management of a posttraumatic pneumonectomy case.

Sir, Tracheobronchial rupture following blunt chest trauma is rare and life-threatening. Surgical repair is done in most cases and pneumonectomy is avoided whenever possible as emergency pneumonectomy carries high mortality rate of 50-70%.[1] This is due to contributory effects of hypotension, hypoxia and abrupt rise in pulmonary vascular resistance leading to right ventricular failure[2] and so postoperative care in intensive care unit (ICU) is very important. We describe ICU management of such a case. An 18-year-old male of chest trauma presented to the emergency referred from another hospital. Vitals were pulse 113/min, blood pressure 152/82 mmHg, respiratory rate (RR) 35/min, saturation 84% with massive subcutaneous emphysema and intercostal chest drain (ICD) in situ. Patient was immediately intubated, and another ICD inserted on the right side. Chest X-ray (CXR) post ICD revealed massive pneumothorax on right side [Figure 1]. Computed tomography chest revealed complete transection of right main bronchus. Patient was shifted to emergency operation theatre and intubated with double lumen tube (DLT). Intraoperatively as bronchial anastomosis was not possible, right sided pneumonectomy was done, and patient was shifted to the ICU. In the ICU, instead of changing to a single lumen tube, we ventilated the patient with DLT [Figure 2] only for 12 h as there were high chances of bronchial stump rupture. Patient was kept on volume control with a tidal volume 5 ml/kg, positive end expiratory pressure (PEEP) of 5 cm H2O, with respiratory rate (RR) adjusted to limit plateau airway pressure to 20 cm H2O. PaCO250-55 mmHg was accepted. Fluid intake was restricted to maintain urine output >0.5 ml/kg/h. Weaning was started after 24 h and patient extubated on the 3rd postoperative day and put on noninvasive ventilation (NIV) intermittently for the next 2 days. CXR was done daily to monitor the fluid in postpneumonectomy space (PPS). With active physiotherapy and mobilization, patient did well and was discharged from ICU on 9th postoperative day [CXR, Figure 3] and from the hospital on 14th day. At the time of discharge, he could climb two flights of stairs without dyspnea. Figure 1 Preoperative chest X-ray of patient showing collapsed lung with intercostal chest drain in situ Figure 2 Postoperative chest X-ray showing left sided double lumen endotracheal tube Figure 3 Chest X-ray on 8th postoperative day showing postpneumonectomy space filled with fluid The common causes of early postoperative death after emergency pneumonectomy are bleeding, postpneumonectomy pulmonary edema, right ventricular failure and arrhythmias,[2] risk factors being increased age, higher injury severity score, right sided pneumonectomy and comorbid condition.[3] The incidence of pulmonary edema is higher for right pneumonectomy but can be avoided with judicious fluid management. We maintained a negative fluid balance of 500 ml/24 h. Radiographic monitoring of PPS is crucial. Immediately after surgery PPS fills with air.[4] Then, fluid accumulates at a rate of two rib spaces per day and 80-90% is filled in 2 weeks. If fluid accumulates more rapidly, then possibility of hemorrhage, infection or chylothorax should be kept in mind. Arrythmias are seen in 9-34% patients, mainly in advanced age group.[5] After pneumonectomy work of breathing increases so patient remains tachypenic. We kept our patient on NIV intermittently and accepted an RR of 25-30/min. In conclusion, adequate knowledge about changes postpneumonectomy and management of complications are vital for a favorable outcome.

P-162EMERGENT PNEUMECTOMY FOR LUNG GANGRENE: DOES THE OUTCOME WARRANT THE PROCEDURE?

Background. Sloughing and gangrene of a complete lung are only very infrequently encountered complications of necrotizing pneumonia and fulminant pulmonary abscess formation. Thus far the role of emergent pneumonectomy is not established. Methods. The outcome of patients who underwent anatomic lung resection for lung gangrene at 3 centers for thoracic surgery during the last 13 years was retrospectively analyzed. Only cases of necrotizing pneumonia were included whereas malignant lesions were excluded.

Management of Giant Congenital Pulmonary Airway Malformations Requiring Pneumonectomy

Congenital pulmonary airway malformation (CPAM) is a rare congenital anomaly that occurs sporadically throughout fetal development. CPAM is usually a lobar process, but involvement of an entire lung is exceedingly rare. We present a small series of patients with multilobar CPAM who, to the best of our knowledge, are the first reported cases of giant CPAMs treated with pneumonectomy at birth. After institutional review board approval, 93 medical records were reviewed for infants 0 to 12 months with congenital cystic adenomatoid malformation (CCAM) from 1990 to 2011. Three patients with entire lung involvement were included. Two patients were identified prenatally by ultrasonography and 1 was diagnosed at birth. Prenatally, the 2 patients exhibited mediastinal shift and steroids were administered. A pericardial effusion and decreased movement developed in 1 patient, requiring an emergent cesarean section at 31 weeks' gestation. All 3 patients underwent immediate newborn resection. One infant went into cardiac arrest on delivery and was resuscitated and taken for emergent resection. The 2 patients delivered vaginally at term tolerated spontaneous ventilation without positive pressure. All 3 patients underwent an emergent pneumonectomy on the first day of life. The premature infant died intraoperatively after CPAM removal from severe pulmonary hypertension (HTN) and contralateral lung hypoplasia. The hospital course for these patients was characterized by prolonged stays in the intensive care unit (ICU), pneumonia, ventilator dependence, and pulmonary HTN. Bronchoscopy revealed tracheomalacia in 1 patient that was relieved by aortopexy; the other patient had bronchomalacia requiring tracheotomy. Emergent total pneumonectomy can be lifesaving, although significant pulmonary HTN can be expected. Management options may include fetal surgical intervention, ex utero intrapartum treatment (EXIT), and expectant management. Extracorporeal membrane oxygenation (ECMO), a prolonged ICU course, and symptomatic tracheomalacia/bronchomalacia may be anticipated. Families can be counseled that survival is achievable with adequate contralateral lung development.

Idiopathic pulmonary hemosiderosis is susceptible to pulmonary zygomycosis

Pulmonary gangrene is an extremely rare and severe complication of pneumonia. It is very rarely seen in community-acquired pneumonia. A 49-year-old immunocompetent man was admitted with community-acquired pneumonia caused by Klebsiella pneumonia. His condition rapidly deteriorated with ensuing pulmonary gangrene and septic shock. He was successfully managed by emergency pneumonectomy.

Emergent Completion Pneumonectomy for Postoperative Hemorrhage from Rupture of the Infected Pulmonary Artery in Lung Cancer Surgery

Completion pneumonectomy (CP) is one of the most difficult procedures and known to be associated with a high morbidity and mortality. A 74-year-old male underwent a left upper lobectomy for pulmonary adenocarcinoma (T3N0M0); six days later after the surgery, he had a sudden postoperative intrathoracic excessive hemorrhage with shock. Emergent redo thoracotomy was performed to treat the bleeding from the ablated interlobar pulmonary artery by suturing with prolene. However, 3 days later after the second operation, he had the second intrathoracic bleeding. Emergent CP was performed with cardiopulmonary bypass by anterior transpericarsial approach via a median sternotomy. The hemorrhage was caused by a rupture of the proximal fragile and infected pulmonary artery. We performed omentopexy for the infected intrathoracic cavity and for covering of the divided main bronchial stump. We had a rare experience of two times of postoperative life-threatening hemorrhage from rupture of the infected pulmonary artery after left upper lobectomy. Emergent CP as salvage surgery should have an advantage in control of infected proximal pulmonary arterial hemorrhage. We should take care of tearing off of adventitia of pulmonary artery in lobectomy because of a possibility of postoperative hemorrhage under a fragility of the injured pulmonary artery with infection.

Emergency Transmediastinal Pneumonectomy for Scimitar Syndrome

Repair of scimitar syndrome presenting in infancy involves either tunneling or reimplantation of the anomalous vein to the left atrium and may be fraught with serious complications such as thrombosis and secondary pulmonary infarction necessitating pneumonectomy. The authors present the case of a severely symptomatic infant with scimitar syndrome, managed initially with closure of an atrial septal defect in the hope of avoiding a repair with considerable risk of scimitar vein thrombosis and pulmonary infarction. Despite initial clinical improvement, subsequent rapid development of spontaneous massive emphysematous degeneration of the right lung necessitated emergency pneumonectomy, which was accomplished via the median sternotomy approach.

Massive Necrotizing Pneumonia With Pulmonary Gangrene

Pulmonary gangrene is an extremely rare and severe complication of pneumonia. It is very rarely seen in community-acquired pneumonia. A 49-year-old immunocompetent man was admitted with community-acquired pneumonia caused by Klebsiella pneumonia. His condition rapidly deteriorated with ensuing pulmonary gangrene and septic shock. He was successfully managed by emergency pneumonectomy.

Total Pulmonectomy in Trauma: A Still Unresolved Problem–Our Experience and Review of the Literature

Emergency pneumonectomy for trauma is associated with very high mortality. Despite significant improvement of the intensive care resources, results of this procedure have not been improved during the last 20 years. When performed because of hemorrhagic shock, pneumonectomy is almost always fatal. We present a series of four patients who underwent total pneumonectomy in our trauma center. The main purpose of this study was to describe pathophysiologic changes and to discuss possible therapeutic alternatives based on the literature review after this operation.

Exsanguinating hemoptysis revealing the absence of left pulmonary artery in an adult

Isolated absence of a pulmonary artery is an exceptional cause of massive hemoptysis. We report a 35-year-old woman with agenesis of the left pulmonary artery who presented with exsanguinating hemoptysis that prompted angiography with the aim to embolize the bleeding vessels selectively. The procedure could not be completed because of the presence of an anterior spinal artery branching from the aberrant systemic-to-pulmonary circulation. The patient successfully underwent an emergent pneumonectomy.

Nitric oxide usage after posttraumatic pneumonectomy

Pneumonectomy is rarely required in the surgical management of thoracic traumatic injuries with high mortality rates. Right heart failure due to elevated pulmonary artery pressure and the adult respiratory distress syndrome have been leading causes of mortality reported after posttraumatic pneumonectomy. The beneficial effect of inhaled nitric oxide has been shown in pulmonary hypertension and in adult respiratory distress syndrome. We report the use of inhaled nitric oxide in the perioperative management of a patient undergoing emergent pneumonectomy.

Morbidity and Mortality After Traumatic Pneumonectomy: The Effect of Compromised Oxygenation and Cardiac Function

I describe the pathophysiological and hemodynamic events that occur after an emergency pneumonectomy for trauma and how they impact on subsequent mortality. Four patients were identified as requiring an emergency right pneumonectomy for trauma at a level 1 Urban Trauma Center within a 39-month period. A retrospective review of their hospital course served as the basis for our analysis. Three patients sustained gunshot wounds and one patient was a victim of blunt trauma. Hemodynamic data were available for three patients who survived more than 24 hours. All patients presented in shock and required massive transfusion. One patient died in the operating room due to air embolism and shock. After pneumonectomy, there was an increase in pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) more than 2 times normal, which coincided with a decrease in stroke volume, cardiac output, and right and left ventricular stroke work (RVSW/LVSW). The RVSW gradually increased to above normal levels by postoperative day 5, whereas the LVSWI remained below normal. Adult respiratory distress syndrome (ARDS) developed in all patients early in the postoperative period. There was evidence of oxygen delivery (DO2) dependent of oxygen consumption (VO2) and the DO2remained below normal despite inotrope administration. The remaining three patients died 7 to 13 days after surgery due to various combinations of ARDS, cardiac failure, and sepsis. Until we have better methods to decrease PAP selectively, traumatic pneumonectomy should be avoided if possible, especially when it involves the right side or is associated with a contralateral lung injury. Early operative intervention and control of the pulmonary hilum may lessen the severity of shock. The hemodynamic changes that occur after pneumonectomy for trauma becomes additive in the presence of ARDS. This combination results in inadequate cardiac function, oxygen transport, and, ultimately, death.

Anterior transpericardial closure of a main bronchus fistula after pneumonectomy

A young woman sustained a penetrating wound to the right anterior chest during a vehicular accident. Septic complications led to emergency pneumonectomy followed by infection of the pleural space and disruption of the right bronchus closure. Her condition improved after creation of a pleural window for dependent drainage and gauze packing of the pleural space. Subsequently, the open bronchial stump was closed utilizing a transpericardial approach through a median sternotomy incision which permitted eventual closure of the pneumonectomy space without thoracoplasty. When the length of the bronchial stump permits its application, the transpericardial approach to postpneumonectomy bronchial fistula closure offers important advantages over conventional transpleural techniques.