Post Pneumonectomy Research Articles

Bronchial stump protective ventilator strategy with low positive end expiratory pressure in post pneumonectomy patient

Bronchial stump protective ventilator strategy with low positive end expiratory pressure in post pneumonectomy patient - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/j.ijca.2023.021, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

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.

Intrathoracic prosthesis in children in preventing post pneumonectomy syndrome: Its role in congenital single lung and post pneumonectomy situations

BackgroundPostpneumopnectomy syndrome (PPS) is an extreme rotation and malposition of mediastinum causing dynamic and symptomatic central airway compression, arisingafter pneumonectomy or more uncommonly, in congenital single lung physiology. Affected patients present with severe respiratory compromise. Intrathoracic prosthesis placement is an evolving technique in children that mitigate the effects of thoracic dead space. Research questionAssessment of clinical recovery and functional benefit in children undergoing placement of intrathoracic prosthesis following pneumonectomy or in congenital single lung situations. Study design and methodsRetrospective chart review of patients at Great Ormond Street Hospital from 2010 to 2020 was performed of all patients who underwent intrathoracic tissue expander placement. We summarize the outcomes of twenty four children, including those with both congenital and postpneumonectomy PPS etiology. Results24 Children who underwent placement of intrathoracic prosthesis for PPS in the study period with median age of 3.5 months and weight of 5 kg. Single lung etiology was congenital in 15 children (6 agenesis, 9 hypoplasia), and postpneumonectomy in 9 children. In seven patients, there was associated long segment tracheal stenosis. Pre operative ECMO was required in 2 patients, and pre operative ventilation was required in 12 patients all of whom had congenital single lung. Intrathoracic prosthesis placement was concurrent with intracardiac repair in 5 patients. There were no operative deaths, but one early postoperative death related to septicaemia. Median follow up was 75 months with 10 patients on continued respiratory support and 3 on nocturnal support with good quality of life. Two children needed reoperations for replacement of prosthesis. ConclusionThe use of tissue expanders is within the armamentarium of most plastic surgeons’ practice. We also therefore advocate for a collaborative team approach involving Plastic and Cardiothoracic Surgery for surgical treatment of these patients. This multidisciplinary strategy has improved management of this rare and debilitating condition of PPS, thereby offering significant improvements in general progress of these sick children having single lung physiology. Evidence is still lacking on functional outcomes in these children and further work is necessary to prove that this is indeed achievable.

Commentary on intrathoracic prosthesis in children in preventing post pneumonectomy syndrome: Its role in congenital single lung and post pneumonectomy situations

This is a Commentary on the manuscript titled "Intrathoracic Prosthesis in Children in Preventing Post Pneumonectomy Syndrome: Its Role in Congenital Single Lung and Post Pneumonectomy Situations" by Quong etal.

A rare complication of left pneumonectomy

Postpneumonectomy syndrome (PPS) is a rare complication of pneumonectomy occurring due to extreme rotation and malposition of mediastinum resulting in dynamic central airway compression between adjacent vascular structures and vertebra. Intrathoracic prosthesis placement is an evolving technique to treat this by alleviating the effects of thoracic dead space. We hereby present a case of post pneumonectomy syndrome which is rare in adults and further rarer following left pneumonectomy as in this case.

Postpneumonectomy respiratory failure and acute respiratory distress syndrome: risk factors and outcome

: Pneumonectomy is related with a high postoperative morbidity and mortality rate, ranging from 5% to 9%. Post-pneumonectomy respiratory failure (ARF) acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are grave and disastrous complications in these patients, necessitating invasive mechanical ventilation (IMV). In different series reported in literature, ARDS after lung resection occurred in 1–8% of patients and the mortality amounts in a range between 30% to 80%. We have reviewed the literature in order to clarify the different risk factors in the development of ARDS post pneumonectomy. According to different papers, the most important pre-operative risk factors are represented by age and sex, comorbidities (smoking, diabetes, COPD), pre-operative respiratory function and right side of pneumonectomy. Concerning peri and immediately post-operative management of these patients, the key role is represented by the IMV and the fluid infusion and cardiac preload during and after surgery. In summary, ALI and ARDS after pneumonectomy are closely linked to any direct or indirect pulmonary insult, responsible of endo-alveolar oedema. An inappropriate fluid infusion during or after surgery, may be exacerbate endo-alveolar oedema and encourage the development of ALI and ARDS. In this perspective, the best management of these patients should be achieved by a multidisciplinary team made by thoracic surgeons, respiratory physicians, anaesthesiologists, physiotherapists and nurses dedicated in ICUs.

R09 Balanced Chest Drainage Prevents Post-Pneumonectomy Pulmonary Oedema

To compare the incidence of post pneumonectomy pulmonary oedema (PPPO) in patients who underwent pneumonectomy and whose empty pleural space was managed either with clamp release drainage (CRD) or balanced chest drainage (BCD).

Balanced Chest Drainage Prevents Post-Pneumonectomy Pulmonary Oedema

Pneumonectomy in the adult patient is associated with a mortality of 1-9%. Death is often due to post pneumonectomy pulmonary oedema (PPPO). The use of balanced chest drainage system (BCD) in the setting of post pneumonectomy has been reported to be of benefit in the prevention of PPPO. This study seeks to compare the incidence of PPPO in patients who underwent pneumonectomy and whose empty pleural space was managed either with CRD or BCD. This retrospective observational cohort study involved 98 patients who were operated on by one surgeon at Liverpool Hospital, Sydney, Australia from 1997 to 2019. The patients were divided into two groups according to the era in which they had their pneumonectomy. Group 1 consisted of 18 patients managed with clamp-release drainage between 1997 and 2002. Group 2 consisted of 80 patients managed with balanced chest drainage between 2003 and 2019. The primary outcomes of interest were the development of PPPO and death. Demographic and clinico-pathological variables between the groups were compared including whether the phrenic nerve was sacrificed, volume of infused intraoperative fluid, duration of single lung ventilation, intraoperative tidal volumes, agents of anaesthetic induction and maintenance, mean urine output in the first 4 postoperative hours, institution of a postoperative 1.5 L fluid restriction, total chest drainage, day of chest drain removal, presence of radiological postoperative mediastinal shift, post-pneumonectomy pulmonary oedema and death. Group characteristics were compared using t-test and chi-squared for continuous and categorical variables respectively. Univariate and multivariate analysis was also undertaken using the Firth method of logistic regression for rare occurrences in a stepwise fashion. Through univariate analysis, balanced chest drainage, postoperative fluid restriction and intraoperative fluid infusion showed significant effect on PPPO. Through multivariate analysis, balanced chest drainage was found to have independent protective value for PPPO and mortality. Compared with clamp-release drainage, balanced chest drainage results in a lower incidence of post-pneumonectomy pulmonary oedema and death.

Precision treatment of post pneumonectomy unilateral laryngeal paralysis due to cancer.

Aim: The aim of this study is to assess the efficacy of external laryngeal medialization acquired through a Gore-Tex implant in a 45 patients affected by unilateral vocal fold paralysis in abduction after pneumonectomy. Method: The cohort of patients was made up of 30 male (73.1%) and 11 female patients (26.9%) with an average age of 66.7 years in a range between 46 and 78 years. Results: The results were analyzed with the objective and subjective analysis of voicing and swallowing. In 95.2% of cases, voice and swallow improvement with statistically significant evidences. Conclusion: We can conclude that Gore-Tex implantation is a simple, reproducible and minimally invasive procedure for management of selected cases of vocal fold unilateral paralysis in the abductory position.

Medical image of the week: post pneumonectomy syndrome

Medical image of the week: post pneumonectomy syndrome

Pulmonary alveolar type I cell population consists of two distinct subtypes that differ in cell fate

Pulmonary alveolar type I (AT1) cells cover more than 95% of alveolar surface and are essential for the air-blood barrier function of lungs. AT1 cells have been shown to retain developmental plasticity during alveolar regeneration. However, the development and heterogeneity of AT1 cells remain largely unknown. Here, we conducted a single-cell RNA-seq analysis to characterize postnatal AT1 cell development and identified insulin-like growth factor-binding protein 2 (Igfbp2) as a genetic marker specifically expressed in postnatal AT1 cells. The portion of AT1 cells expressing Igfbp2 increases during alveologenesis and in post pneumonectomy (PNX) newly formed alveoli. We found that the adult AT1 cell population contains both Hopx+Igfbp2+ and Hopx+Igfbp2- AT1 cells, which have distinct cell fates during alveolar regeneration. Using an Igfbp2-CreER mouse model, we demonstrate that Hopx+Igfbp2+ AT1 cells represent terminally differentiated AT1 cells that are not able to transdifferentiate into AT2 cells during post-PNX alveolar regeneration. Our study provides tools and insights that will guide future investigations into the molecular and cellular mechanism or mechanisms underlying AT1 cell fate during lung development and regeneration.

Emergency drain for post pneumonectomy bronchopleural fistula: a drain placement technique based on the siphon principle.

Post pneumonectomy bronchopleural fistula (BPF) is a life-threatening complication requiring pleural cavity drainage to avoid acute mediastinal shift and contralateral aspiration pneumonia. Chest drain insertion in this situation may be technically difficult because of drastic anatomical changes such as mediastinal dislocation, diaphragm elevation and, sometimes, massive subcutaneous emphysema. In addition, the most important part of the pleural cavity to be drained is the costophrenic recess that is scarcely drained by a standard chest tube with its tip aiming high and upwards. We propose a safe, simple and effective technique based on the siphon principle to drain the lowest part of the pleural cavity.

Segmental Lung Isolation in a Postpneumonectomy Patient Undergoing Contralateral Lung Resection

Lung isolation is a technique commonly used in thoracic surgery to improve surgical access, especially in patients undergoing minimally invasive procedures. Selective lobar blockade has been described for patients who cannot tolerate complete lung isolation and, less commonly, for patients who have undergone previous pneumonectomy.1, 2 Selective lobar blockade may also benefit patients with compromised oxygenation by reducing pulmonary shunting, compared with complete lung collapse.3 To our knowledge, there are no reports of selective segmental isolation in the literature. We present the case of a post pneumonectomy patient with a new primary malignancy scheduled for lung resection.

遊離肋軟骨片を用いて肺全摘後主気管支断端瘻を閉鎖しえた1例

遊離肋軟骨片を用いて肺全摘後主気管支断端瘻を閉鎖しえた1例

Cytic Presentation of Lung Adenocarcinoma: A Rare Entity

67 year old male presenting with worsening cough, hemoptysis, shortness of breath and weight loss over the last 6 months. He has a 50 pack year history of smoking tobacco, with no reported past medical history. Chest radiography showed a complete opacification of left lung with mediastinal shift to the right (Figure 1A). A computed Tomography of the chest disclosed a complex predominantly cystic lesion within the left hemithorax with mass effect on left upper quadrant visceral organs and mediastinal shift to the right (Figure 1B and 1C). Histopathological examination of the tissue sample obtained post pneumonectomy revealed a lung adenomacarcinoma of acinar type.

Endogenous Distal Airway Progenitor Cells, Lung Mechanics, and Disproportionate Lobar Growth Following Long-Term Postpneumonectomy in Mice

Using a model of postpneumonectomy (PNY) compensatory lung growth in mice, we previously observed an increase in numbers of a putative endogenous distal airway progenitor cell population (CCSP(pos) /pro-SPC(pos) cells located at bronchoalveolar duct junctions [BADJs]), at 3, 7, and 14 days after pneumonectomy, returning to baseline at 28 days post-PNY. As the origin of these cells is poorly understood, we evaluated whether bone marrow cells contributed to the pool of these or other cells during prolonged post-PNY lung regrowth. Naïve and sex-mismatched chimeric mice underwent left PNY and were evaluated at 1, 2, and 3 months for numbers of BADJ CCSP(pos) /pro-SPC(pos) cells and presence of donor-derived marrow cells engrafted as airway or alveolar epithelium. Nonchimeric mice were also examined at 12 months after PNY for numbers of BADJ CCSP(pos) /pro-SPC(pos) cells. Notably, the right accessory lobe (RAL) continued to grow disproportionately over 12 months, a novel finding not previously described. Assessment of lung mechanics demonstrated an increase in lung stiffness following PNY, which significantly diminished over 1 year, but remained elevated relative to 1-year-old naïve controls. However, the number of CCSP(pos) /pro-SPC(pos) BADJ cells ≥1-month following PNY was equivalent to that found in naïve controls even after 12 months of continued RAL growth. Notably, no donor bone marrow-derived cells engrafted as airway or alveolar epithelial cells, including those at the BADJ, up to 3 months after PNY. These studies suggest that lung epithelial cells, including CCSP(pos) /pro-SPC(pos) cells, are not replenished from marrow-derived cells during post-PNY lung growth in mice.

Is the preservation of the phrenic nerve important after pneumonectomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: is the preservation of the phrenic nerve important after pneumonectomy? Altogether more than 49 papers were found using the reported search, of which four represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that care should be taken to preserve the integrity of the phrenic nerve wherever possible. The abnormal diaphragmatic motion which occurs as a consequence of phrenic nerve damage significantly reduces expiratory lung volumes, gas exchange and exercise capacity in already compromised patients. Phrenic nerve injury can also lead to a prolonged need for mechanical ventilation; this alone carries a risk of complication, such as infection. Plication of the paralyzed hemi-diaphragm has proved effective in reducing respiratory insufficiency after pneumonectomy. The aim of this is to fix and flatten the diaphragm, thus mimicking the role of a functioning phrenic nerve. Furthermore, the function of a preserved phrenic nerve remains normal for up to 11 years post pneumonectomy. Therefore, deterioration in function may highlight a recurrence in disease or a change in the post pneumonectomy space.

A phase I safety and pharmacokinetic (PK) study of the PI3K inhibitor XL147 (SAR245408) in combination with erlotinib in patients (pts) with advanced solid tumors.

3070 Background: The PI3K pathway is frequently dysregulated in cancer cells and has been implicated as a mechanism of resistance to EGFR inhibitors. In preclinical xenograft models, the oral, selective Class I PI3K inhibitor XL147 augments the anti-tumor efficacy of EGFR inhibitors including erlotinib (E). Methods: A standard 3 + 3 design was used with a maximum tolerated dose (MTD) cohort expansion in NSCLC pts. E is dosed qd, and XL147 is dosed qd on days 1-21 of each 28-day cycle. Dose limiting toxicities are determined using cycle 1 safety data. Tumor response is evaluated every 8 weeks. Results: 23 pts with diverse advanced solid tumors have been enrolled including 8 NSCLC and 5 CRC. Pts have been treated at 7 dose levels up to 600 mg XL147/150 mg E. The most frequently reported related AEs were rash (45%), nausea (30%), diarrhea, fatigue and vomiting (each 20%). One pt (status post pneumonectomy) treated with XL147 600 mg and E 150 mg had a treatment-related SAE of DRESS (drug rash with eosinophilia and systemic symptoms) syndrome and died from progressive disease and DRESS. No major PK interaction between XL147 and E was evident across cohorts based on comparison with single agent data. In tissue biopsies, robust inhibition of the PI3K and MAPK/EGFR signaling pathways was evident. For example, in serial tumor biopsies from a pt with an ethmoid tumor, maximum reductions in pAKT- T308 (61%), pERK (68%), and pEGFR (68%) were evident at day 43 post-dose, with a corresponding reduction in Ki67 (45%) and induction of apoptosis (2.6-fold). One EGFR inhibitor-naïve NSCLC pt had a confirmed PR (59% reduction in the sum of target lesions). One pt with adenoid cystic carcinoma had a decrease in FDG uptake by PET and a decrease in size of a lung nodule by CT. One pt with HNSCC (left maxillary alveolar ridge) had a decrease in FDG uptake by PET and a shrinkage of the primary tumor bulk by CT. Eight pts continued on treatment ≥ 16 weeks, including 5 pts on treatment ≥ 24 weeks. Conclusions: The combination of XL147 and E is generally well tolerated at doses up to 400 mg XL147/150 mg E with no major PK interaction and results in clinical activity and robust simultaneous inhibition of PI3K and EGFR signaling. Author Disclosure Employment or Leadership Position Consultant or Advisory Role Stock Ownership Honoraria Research Funding Expert Testimony Other Remuneration Exelixis Exelixis Exelixis Exelixis

Imagerie du thorax post-opératoire : les aspects normaux

Chest radiographs and CT are especially useful for the follow-up of patients after lung resection. The purpose of this paper is to illustrate normal postsurgical imaging findings that differ according to the type of surgery (pneumonectomy, lobectomy, segmentectomy and wedge resection). Anatomic changes induced by surgery affect the remaining lung, pleura and chest wall, mediastinum and diaphragm. After pneumonectomy, there is accumulation of fluid in the post pneumonectomy space, progressive chest retraction with mediastinal shift toward the operated side and elevation of the ipsilateral hemidiaphragm. After lobectomy, there is hyperexpansion of the remaining lung, mediastinal shift and intercostal space narrowing. Theses findings are different according to the delay after surgery. Knowledge of the variable imaging features is necessary to detect complications and to provide appropriate follow-up of the primary disease.

Thoracoplasty for the Management of Postpneumonectomy Empyema

Persistent postpneumonectomy empyema space is a difficult problem. Various operative procedures are described for its management. These include space sterilization procedures e.g. Clagett procedure, space filling with muscle flaps and space collapse procedures such as thoracoplasty. Andrew's thoracoplasty, originally used for cavitary pulmonary tuberculosis, is a valuable operative procedure in the management of persistent postpneumonectomy empyema space. We present a case in which a diagnostic radiological aspiration five years postpneumonectomy resulted in empyema in the postpneumonectomy space. Management of the patient involved involved a combination of space reduction and space filling with muscle flaps. This case highlights the risks of interventions in the post pneumonectomy space and the value of time-honored thoracoplasty.