Postpneumonectomy Space Research Articles

Nil Intervention is at Times the Best Intervention

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the pneumonectomy space (BEPS). We report a 28-year-old female patient who presented to a tertiary care referral centre, in Pondicherry, India in 2020 with multiple episodes of vomiting. Subsequent to a left-sided pneumonectomy due to tuberculosis, she was diagnosed with BEPS. Generally, patients with BEPS are clinically stable, afebrile with no fluid expectoration and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. In terms of management, close monitoring and early detection of a bronchopleural fistula are the key points. BEPS should be a differential diagnosis in case of a drop in the air-fluid level of the post-pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions. Keywords: Pneumonectomy; Pleura; Hydropneumothorax; Case Report; India.

Nil Intervention is at Times the Best Intervention

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the post pneumonectomy space (BEPS). We herein report a case of benign emptying of pneumonectomy space, briefly review the literature and enumerate possible mechanisms for the same. It is an extremely rare entity and follows a benign course. Patients with BEPS are clinically stable, afebrile with no fluid expectoration, and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. Close monitoring and early detection of a bronchopleural fistula is the management. Clinicians should keep BEPS among the differential diagnosis in case of a drop in the air-fluid level of the post pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions.
 Keywords: Pneumonectomy; BEPS; Bronchopleural Fistula; India.

Patterns of topographic and anatomical changes in body cavities after pneumonectomy

Purpose of the study. To study and describe the general patterns of topographic and anatomical changes after pneumonectomies on the basis of this study.Materials and methods. Computed tomograms of the chest of 53 patients (50 men and 3 women) aged 39 to 75 years before and after pneumonectomy (26 on the left, 27 on the right) were examined. Postoperative computed tomography was performed on the 10–12th day after the operation, 6 and 12 months after the intervention. The transverse, anteroposterior and angular displacements of organs and structures of the mediastinum, chest wall, and abdomen were studied. Changes in their skeletotopic and holotopic characteristics were assessed. Calculations of the volumes of the postpneumonectomy space and the remaining lung were performed.Results. Pneumonectomy causes regular, causal topographic and anatomical changes in the abdominal cavity and retroperitoneal space. Displacement of organs and large vessels of the mediastinum after pneumonectomy has a multi-vector character of varying severity. Among the mediastinal organs, the most pronounced changes after pneumonectomy are the heart, which is displaced laterally, posteriorly and upward. Changes in the chest wall after pneumonectomy on the side of the operation are expressed in it, changes in the angles of inclination of the ribs, scoliotic deformity of the thoracic spine. Pneumonectomy leads to the rise of the dome of the diaphragm on the side of the operation to a height of 1–5 ribs with the corresponding topographic and anatomical changes in the abdominal cavity and retroperitoneal space. Anatomical changes in the remaining lung are expressed in a partial decrease in its volume in the early postoperative period, followed by an increase in volume in the long term and the gradual formation of predominantly anterior mediastinal hernia. Postpneumonectomy cavity is reduced in the postoperative period by changing its shape. The general dynamics of changes after pneumonectomies is their occurrence in the early postoperative period, gradual progression during the year and subsequent stabilization.Conclusion. Regular post-pneumonctomic changes in the chest and abdomen must be taken into account when performing surgical interventions and invasive research methods. They can serve as a basis for clinical and functional studies of the abdominal organs in the postoperative period. They should be used in the development of postoperative diagnostic and treatment methods.

A CASE OF RECURRENT PNEUMOTHORACES IN A NEWBORN

TOPIC: Pediatrics TYPE: Fellow Case Reports INTRODUCTION: Recurrent pneumothroaces (PTX) is an uncommon presentation in the newborn period, often associated with prematurity or ventilator use. This is a case of rapidly progressive cystic disease in the setting of an absent right pulmonary artery. CASE PRESENTATION: Patient is a 18do female, ex-37 weeks gestation, with negative prenatal history. Noted at birth to have meconium aspiration at birth, cyanosis and non-invasive positive pressure ventilation (PPV) at 9 hours of life. CXR showed R PTX, that was resolved with chest tubes and discharged on day of life (DOL) 11. Presented on DOL) 17 with respiratory distress and was found to have a PTX. Chest CT showed R PTX with cystic foci in all three lobes thought to be related to pulmonary interstitial emphysema (PIE). Cardiothoracic surgery felt patient was too young for surgery and recommended more conservative management. Presented on DOL 27 with recurrrent PTX and then again at 3 months of life. Chest CT at this time showed a absent R pulmonary artery not previously recognized. ECHO confirmed absence of R PA. Patient underwent R pneumonectomy with mediastinal tent placement. Pathology showed pneumatoceles in lower lobes, focal areas of dysplastic lung development, absent large hilar pulmonary arteries, lymphangiectasis and pleural fibrosis. Cytology showed few multinucleated giant cells and fibroblastic proliferation along pneumatocele wall. DISCUSSION: Air leak syndromes such as PTX and PIE are more common in neonates with prematurity, need for PPV, meconium aspiration, and pulmonary hypoplasia. The presence of meconium aspiration and need for PPV likely contributed to the initial pulmonary insult that led to her clinical picture. Persistent PIE can associated with multiple large pseudocysts. Presence of multinucleated giant cells with fibroblast proliferation in cytology further supports presence of persistent PIE. In addition the unilateral absence of the R pulmonary artery (UAPA) can contribute to hypoperfusion and hypoplasia. This can subsequently lead to the cystic development especially when there are multiple other insults to the lung as seen in this patient. Post-pneumonectomy complications include concern for development of pulmonary hypertension as well as complication related to the post-pneumonectomy space, such as mediastinal shift causing compression of the airways. CONCLUSIONS: Recurrent PTX can be due to a wide variety of etiologies based on patient's age and presentation. This case highlights recurrent PTX in a neonate in the setting of cystic lung disease that is likely from persistent PIE with further contribution from a unilaterally absent pulmonary artery. REFERENCE #1: Jeng, M.J., Lee, Y.S., Tsao, P.C. & Soong, W.J. Neonatal air leak syndrome and the role of high-frequency ventilation in its prevention. J Chin Med Assoc 75, 551-559 (2012). REFERENCE #2: Agrons, G.A., Courtney, S.E., Stocker, J.T. & Markowitz, R.I. From the archives of the AFIP: Lung disease in premature neonates: radiologic-pathologic correlation. Radiographics 25, 1047-1073 (2005). REFERENCE #3: Kruzliak, P., Syamasundar, R.P., Novak, M., Pechanova, O. & Kovacova, G. Unilateral absence of pulmonary artery: pathophysiology, symptoms, diagnosis and current treatment. Arch Cardiovasc Dis 106, 448-454 (2013). DISCLOSURES: No relevant relationships by Ashish George, source=Web Response no disclosure on file for Robin Ortenberg; No relevant relationships by Swaroop Pinto, source=Web Response

Short- and long-term outcomes of thoracoscopic pneumonectomy - single center experience.

IntroductionThe video-assisted thoracic surgery (VATS) approach is widely used for pulmonary lobectomy, but its application for pneumonectomy is much less common and outcomes are ambiguous.AimTo evaluate the feasibility and outcomes of VATS pneumonectomy.Material and methodsThis retrospective study included 19 patients with the mean age of 62.6 ±5.5 years who were qualified for VATS pneumonectomy between September 1, 2010, and January 31, 2020. Indications and technical aspects were analyzed. Moreover, short- and long-term outcomes were assessed.ResultsThere were no intraoperative deaths. Conversion to thoracotomy was necessary in 2 (10.5%) patients, because of bleeding in 1 patient and technical reasons in another. One patient died during the in-hospital period due to multi-organ failure as a result of bronchopleural fistula. Five other subjects developed postoperative complications, most often atrial fibrillation (n = 3). One patient was readmitted for empyema of the postpneumonectomy space without bronchopleural fistula. Histopathological examination revealed that the resection was complete (R0) in all cases and the most common type of cancer was squamous cell carcinoma (79%). Seven patients died during the follow-up: 1 because of surgical complications, 4 as a result of cancer progression, and 2 for non-cancer related reasons. Median survival was 47 months. One- and five-year probability of survival estimated by means of the Kaplan-Meier method was 0.88 ±0.07 and 0.43 ±0.15, respectively.ConclusionsVATS pneumonectomy can be performed safely, without increased risk of intraoperative and postoperative complications. It enables a complete lung cancer resection and is likely to provide good short- and long-term outcomes.

Bronchoscopic treatment of a bronchopleural fistula after pneumonectomy.

Bronchoscopic treatment of a bronchopleural fistula after pneumonectomy.

EP1.17-14 Less Is More: An Unusual Case of Benign Emptying of the Post - Pneumonectomy Space

To describe an unusual case of benign emptying of the post-pneumonectomy space. A 68-years-old man presented to our clinic with a large swelling located on the previous thoracotomy increasing at Valsalva maneuvers. One month before he underwent right pneumonectomy for lung adenocarcinoma. He was discharged on the seventh post-operative day uneventfully. Patient denied any history of chest trauma, fever, neither productive cough nor vomica. Chest X-Ray showed a drop of the air-fluid level within the post-pneumonectomy space. Suspecting of a broncho-pleural fistula (BPF), patient underwent a flexible fiberoptic bronchoscopy which showed a regular bronchial stump. A chest CT-scan revealed an empty right hemithorax associated with an air collection in the subcutaneous tissues. No pleural puncture was performed, in order to avoid any contaminations of the pleural cavity. A BPF was ruled out; a watchful waiting approach without surgical intervention or antimicrobial therapy was decided. A roentgenogram 10 weeks later showed the almost refill of the pleural cavity and at physical examination the swelling was dramatically decreased. At chest CT-scan 3 months later the post-pneumonectomy space was completely filled by fluid associated with an overexpansion of the residual lung. After one year the patient is healthy and disease-free. Patient’s presentation meets the clinical and laboratory criteria of Benign Emptying of the Postpneumonectomy Space (BEPS) (afebrile, normal WBC, no fluid expectoration, negative bronchoscopy, negative pleural culture if performed). Among the hypotheses about the pathogenesis of BEPS we advocated the valve-like mechanisms of “occult bronchopleural fistula”, which was large enough to let enter only air into the postpneumonectomy space although arresting the passage of pleural effusion to the airways. A spontaneous healing of the micro-fistula was maybe the underlying mechanisms of the refilling of the thoracic cavity. BEPS seldom occurred after pneumonectomy although it should be considered during differential diagnosis of a sudden drop of the pleural fluid especially in asymptomatic patients, in order to avoid unnecessary invasive procedures. Benign emptying of the postpneumonectomy space should be considered when facing with a sudden drop of the pleural fluid in asymptomatic patients in order to avoid unnecessary invasive procedures.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation.

Video-Thoracoscopic Management of Postpneumonectomy Empyema.

Postpneumonectomy empyema (PPE) is a serious complication even when it is not associated with bronchopleural fistula (BPF). Besides irrigation, an aggressive treatment is usually applied for removing infected material. However, a minimally invasive approach might achieve satisfactory results in selected patients. We retrospectively identified 18 patients presenting with PPE receiving video-thoracoscopic approach. Of these 18 patients, pneumonectomy was performed for nonsmall cell lung cancer in 15 cases, for mesothelioma in 2, and for trauma in 1 case. There were 14 males and 4 females, (mean age, 62 years; range, 44-73 days). Empyema was confirmed by thoracentesis and bacteriological examination. All patients had immediate chest tube drainage and underwent thoracoscopic debridement of the empyema. Fifteen patients had no proven BPF; two had suspicious BPF, and one had a minor (<3 mm) BPF. Median time from pneumonectomy to empyema diagnosis was 129 days (range, 7-6205 days). Median time from drain position to video-assisted thoracoscopic surgery (VATS) procedure was 10 days (range, 2-78 days). A bacterium was isolated in 13 cases (72.2%). There was no mortality and no morbidity related to the procedure. The average duration of thoracoscopic debridement was 56 minutes (range, 40-90 minutes). Median postoperative stay was 7 days (range, 6-18 days). Only in one patient an open-window thoracostomy was performed. Median follow-up of the 18 patients receiving thoracoscopy was 41.5 months (range, 1-78 months). None had recurrent empyema. The patient with a minor BPF remained asymptomatic and is doing well at 48 months follow-up. Thoracoscopy might be a valid approach for patients presenting with PPE with or without minimal BPF. Video-thoracoscopic debridement of postpneumonectomy space is an efficient method to treat PPE.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Postoperative Bedside Critical Care of Thoracic Surgery Patients.

Benign emptying of the post-pneumonectomy space: recognizing this rare complication retrospectively.

Patients presenting with a sudden drop in the pleural fluid level after a pneumonectomy in the absence of a recognizable bronchopleural fistula (BPF) have been classified as cases of benign emptying of the post-pneumonectomy space (BEPS). A retrospective study of 1378 pneumonectomies identified 4 cases of BEPS (0.29%). The patients were men; median age 64 years and all had undergone a right pneumonectomy. The median time at diagnosis was 31 days postoperatively and the median follow-up time was 31 months. None of the patients experienced a documented BPF or empyema. Although BEPS is an extremely rare complication, early recognition and close patient monitoring will prevent unnecessary interventional strategies.

Benign emptying of the postpneumonectomy space.

A drop in the air-fluid level in the postpneumonectomy space on a chest radiogram is an early sign of bronchopleural fistula (BPF). Any suspicion of BPF points to the need for urgent evaluation and appropriate management. Very rarely may this drop occur without the existence of a fistula, but such a condition is defined as benign emptying of the postpneumonectomy space. We share our successful conservative management in a case of postpneumonectomy space emptying with a suspicion of BPF.

Is it safe not to drain the pneumonectomy space?: Table 1:

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether it is safe not to position any chest drain into the pneumonectomy space at the conclusion of the procedure. Altogether 381 relevant studies were identified of which 11 represented the best evidence to answer the question. The author, journal, date, country of publication, alternative methods of postpneumonectomy space (PPS) management, complications and relevant outcomes are tabulated. The majority of studies are on the basis of expert opinion or small cohorts. Major cohorts, by which the pneumonectomy outcomes have been examined, demonstrated that the rates of complications related to pneumonectomy space management such as empyema, bronchopleural fistula, mediastinal shift and major bleeding requiring reopening are very low. In a large cohort where 408 patients underwent pneumonectomy the rate of relevant complications was low and also it was concluded that the PPS drainage is not necessary. Two separate expert opinions were in agreement that needle aspiration in the absence of a drainage system is adequate for the management of PPS and avoiding a mediastinal shift. One small cohort and one institutional audit directly examined the impact of a drainage versus no drainage approach in the management of PPS. Although neither study could show a significant superiority of one method over another, they recommended adopting a unified institutional protocol for current departmental practice. They also emphasized that larger cohorts are required to examine the superiority of different strategies for PPS management. In a cohort of 291 patients, it was demonstrated that patients with drainage with underwater seal are more at risk of postpneumonectomy oedema. A recent review published as a book chapter appraised the relevant literature in both humans and animals. The authors concluded that the simplicity of a no-drainage system is notable; however, a balanced drainage might be recommended for local protocols. We conclude that although the current evidence is not adequate to examine the different aforementioned approaches, not draining the pneumonectomy space can be performed safely.

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.

左肺全摘除術後2ヶ月でBenign Emptying of the Postpneumonectomy Space（BEPS）を認めた1例

背景．肺全摘術後の稀な合併症としてBenign Emptying of the Postpneumonectomy Space（BEPS）という病態がある．"肺全摘術後に，胸部X線上術側の液面低下を認めるが，気管支断端瘻もしくは膿胸の病態では説明のつかない無症候性臨床所見を呈する現象"と定義されている．症例．60歳代女性．検診で異常影を指摘され，胸部CTで左上葉に16 mmの結節を認めた．転移が疑われた肺門部リンパ節が肺動脈へ浸潤していたため，左肺全摘除術を行い（adenocarcinoma，pT1aN1M0 stage IIA），術後1ヶ月より補助化学療法を行った．1コース終了時，胸部X線上術側の液面低下を認めた．気管支断端瘻が疑われたが，気管支鏡で瘻孔を認めず，BEPSと診断し保存的治療とした．術後1年6ヶ月が経過した現在も左胸腔は完全な空洞だが，全身状態は良好であり，無再発生存中である．結論．BEPSは気管支断端瘻，引き続く膿胸との鑑別が重要で，通常は除外診断となる．侵襲的な治療を要さない病態として念頭に置くべきである．

Free Deep Inferior Epigastric Perforator Flap Used for Management of Post-Pneumonectomy Space Empyema

Various solutions exist for management of post-pneumonectomy space empyema. We describe the use of a free deep inferior epigastric perforator (DIEP) flap to fill the space and close a pleural window. Previously, flaps involving abdominal muscle or omentum have been used for this purpose. Abdominal surgery to harvest such flaps can impair ventilatory mechanics. The DIEP flap--harvested from the abdomen, and composed primarily of skin and muscle avoids this problem, thus is a desirable technique in patients with impaired lung function. We believe this is the first report of the DIEP flap to close a postpneumonectomy empyema space.

Benign Emptying of Postpneumonectomy Space Due to Severe Dehydration

Causes of benign emptying of the postpneumonectomy space include small bronchopleural fistulas with spontaneous healing and escape of fluid into the chest wall or diaphragm. We present an additional cause: severe dehydration. As postpneumonectomy empyema usually involves drainage of the pleural space, it is important to be aware of this uncommon cause so as to avoid unnecessary instrumentation and contamination of the postpneumonectomy space.

The intrathoracic vacuum-assisted closure device in case of post-pneumonectomy empyema

We have read with great interest the article by Rocco et al. [1] reporting right-sided post-pneumonectomy empyema management in 3 cases by open-window thoracostomy and the subsequent application of the vacuum-assisted closure device (VAC). Remarkably, the intrathoracic VAC therapy was performed in an outpatient setting with bedside changes of the wound dressing every 3 days. The authors describe that VAC therapy was efficient in draining the post-pneumonectomy space and helped obliterate it. No information is given about the treatment’s efficiency in healing broncho-pleural fistula. However, in their experience, VAC therapy was discontinued in 2 of the 3 patients because of the development of severe side-effects including hypotension and intolerable chest pain. Also, in 1 patient, the VAC foam was entrapped by granulation tissue and its removal was considered difficult through the narrow thoracostomy. We have recently published a series of 27 consecutive patients who underwent intrathoracic VAC therapy for the management of severe intrathoracic infections, including post-resection empyema with or without broncho-pleural fistula [2]. In our experience, the intrathoracic VAC treatment was well tolerated by these high-risk patients; in particular, we did not observe haemodynamic impairment or difficulties of pain control. VAC treatment was completed in all patients and allowed for efficient control of intrathoracic infection and closure of broncho-pleural fistula when present. Our more favourable experience applying negative pressure wound therapy in these patients may be explained by a difference in our technical approach: in case of broncho-pleural fistula, the bronchial stump is debrided and closed by a pediculated muscle transposed into the chest cavity. The intrathoracic VAC dressing is then applied as an adjunct to surgery for efficient drainage, and accelerated obliteration of the chest cavity. In contrast to Rocco et al., we feel more comfortable keeping these critically ill patients in the hospital during the course of VAC therapy and performing the successive VAC dressing changes under a short general anaesthesia. This is convenient for both the patient and the surgeon as the procedure is painless and efficient. General anaesthesia allows for accurate inspection of the chest cavity, debridement if necessary and easy replacement of the VAC foam. Another advantage is that an openwindow thoracostomy is not required, since the intrathoracic VAC dressing can be accessed by repeated opening of the thoracotomy. Standard perioperative monitoring also permits the assessment and immediate correction of potential haemodynamic changes while packing the cavity. Once the infection is controlled and granulation tissue is abundant throughout the cavity, the residual space, if present, is filled with an antibiotic solution and final chest closure is performed. In our published series, none of the patients required chest wall reconstruction procedures as no open-window thoracostomies had been performed. The median length of VAC therapy was 22 days and the median number of VAC changes per patient was 6. We concluded from our experience that the intrathoracic VAC therapy is a safe, well tolerated and effective treatment for the management of severe intrathoracic infections. In our opinion, it should be considered in selected patients as an alternative to open-window thoracostomy. The major advantages are the preserved integrity of the chest wall and a short and efficient treatment course, considerably affecting patients’ satisfaction. However, we would not recommend this approach for bedside dressing changes in an outpatient setting.

Contralateral Pneumothorax Draining via Postpneumonectomy Space

Contralateral pneumothorax is a rare complication after pneumonectomy. We present a patient with bullous emphysema and a defect in the medial wall of a ventrally located bulla that drained via the postpneumonectomy space, producing subcutaneous emphysema without a pneumothorax in the remaining lung. The patient fully recovered after conservative treatment.