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Chest X-ray showing homogenous infiltrates (ARDS) of the non-operated lung and inserted inter-costal drain into the right chest post-pneumonectomy cavity.
Source publication
Post-pneumonectomy air leak and severe respiratory failure of the non-operated lung is considered to be a life-threatening complication of lung surgery. We present the case report of a 68-year-old man who underwent a right pneumonectomy for spinocellular carcinoma. Refractory respiratory failure occurred following bronchial stump air leakage and ad...
Context in source publication
Context 1
... on the 8 th postoperative day (POD) the patient's respiratory status suddenly deteriorated; a chest X-ray revealed right-sided pneumothorax and homogenous ARDS-related infiltrates of the non- operated left lung. An inter-costal drain was inserted into the right hemothorax, but neither permanent air leakage nor methylene blue, bronchoscopically intro- duced into the right bronchial stump, was detected in the chest tube (Figure 1). "Mixed" respiratory failure (pH 6.9, pCO 2 20 kPa, pO 2 7.4 kPa, lactate 6.8 mmol/l, PaO 2 / FiO 2 79) with hemodynamic compromise prompted the need for aggressive mechanical ventilation (Pressure Extracorporeal membrane oxygenation in the management of post-pneumonectomy air leak and adult respiratory distress syndrome of the non-operated lung Szkorupa ...
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Citations
... A case series of ten awake patients on ECMO due to post-operative ARDSseven of them after thoracic procedure-reported 80% survival, which supports earlier weaning off the ventilator [43]. Furthermore, there are several case reports on the use of VV ECMO following pneumonectomy due to trauma [44] or oncologic surgery [45] with good outcomes. ...
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... Lung protective invasive ventilation in combination with ECMO, promoting lung rest and healing or closure of fistulae have been used in cases of air leaks [14][15][16][17], alternatively awake VV ECMO can provide a bridge to diagnosis, treatment and recovery whilst avoiding potentially injurious PPV altogether. ...
A broncho-cutaneous fistula (BCF) is a communicating tract between the bronchus and the cutaneous surface of the thoracic wall and can be the primary presenting sign of several disease processes. It has been associated with positive pressure ventilation (PPV), post pneumonectomy, thoracostomy tubes, perforating chest trauma, neoplasia and chronic empyema. We report a case of a 45-year-old immunocompetent man presenting with severe hypercapnic respiratory failure secondary to a BCF as a result of tuberculosis (TB)-related empyema necessitans. Veno-venous extracorporeal membrane oxygenation (VV ECMO) was employed during spontaneous breathing to mitigate the risks of PPV and to facilitate diagnostics and enable targeted treatment. Awake VV ECMO is an effective supportive therapy for complex, destructive lung pathologies with a known reversible aetiology in which PPV would be potentially detrimental.
Objectives:
To analyze the perioperative management of veno-venous extracorporeal membrane oxygenation (VV ECMO) in patients undergoing major noncardiac surgical procedures, which is poorly described in the literature. In doing so, perioperative challenges related to hemodynamic instability, impaired gas exchange, bleeding, and coagulopathy will be quantified.
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Retrospective, nonrandomized, observational study.
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A single, university-affiliated, quaternary medical center.
Participants:
Fourteen patients who underwent 21 noncardiac surgical procedures during the period of January 1, 2014, through April 1, 2016. Approval for this study was obtained from the Duke University Medical Center Institutional Review Board (study Pro00072723).
Interventions:
None.
Measurements and main results:
Fifty percent of subjects were alive at 1 year after ECMO cannulation. Anesthetic type was variable with an inhaled anesthetic utilized in 71.4% of events, a presurgical continuous sedative was continued in 81.0% of cases, fentanyl was utilized in 100% of encounters, and midazolam was utilized in 71.4% of encounters. Intraoperatively, 50% of encounters resulted in an oxygen desaturation with a peripheral oxygen saturation assessed by pulse oximetry (SpO2)<90%, and 15% of procedures resulted in a SpO2 <80%. A vasopressor, most commonly epinephrine, was used during 66.7% of procedures. Intraoperatively, blood was administered in 52.4% of procedures, fresh frozen plasma was administered in 23.8% of procedures, and platelets were administered in 28.6% of procedures. Hemoglobin levels remained stable throughout the perioperative period, averaging 9.5 g/dL preoperatively, 9.7 g/dL immediately postoperatively, and 9.5 g/dL 24 hours after surgery.
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VV ECMO patients can be anesthetized using either inhalational or intravenous anesthetics. Patient hemodynamics, oxygenation, and decarboxylation require frequent interventions, but can typically be optimized to meet clinically acceptable thresholds.
Objective:
Postpneumonectomy acute respiratory failure leading to invasive mechanical ventilation carries a severe prognosis, especially when acute respiratory distress syndrome develops. The aim of this study was to describe the risk factors, management, and outcome of postpneumonectomy acute respiratory distress syndrome.
Methods:
We retrospectively reviewed the clinical files of patients undergoing pneumonectomy in a single center between 2005 and 2015. Risk factors for acute respiratory distress syndrome, management characteristics, and short- and long-term outcomes were assessed.
Results:
Among the 543 patients undergoing pneumonectomy, 89 (16.4%) needed reintubation within the 30th postoperative day, including 60 (11%) who developed acute respiratory distress syndrome. At multivariate analysis, right-side pneumonectomy (odds ratio [OR], 2.75; 95% confidence interval [CI], 1.51-5.02; P = .0009) and higher Charlson Comorbidity Index (OR, 1.26; 95% CI, 1.07-1.49; P = .007) were identified as independent risk factors for acute respiratory distress syndrome. Operative mortality was 8.1% for all pneumonectomies, 43.8% (n = 39/89) in intubated patients, and 56.7% (34/60) in patients with acute respiratory distress syndrome. Mortality was higher in severe (25/36, 69.4%) than in mild or moderate acute respiratory distress syndrome (9/24, 37.5%, P = .014). Logistic regression identified 3 independent predictors of operative mortality in patients with acute respiratory distress syndrome: age (OR, 1.08; 95% CI, 1.01-1.15; P = .02), right pneumonectomy (OR, 5.97; 95% CI, 1.33-26.71; P = .02), and severe acute respiratory distress syndrome (OR, 7.19; 95% CI, 1.74-29.73; P = .006). Five-year survival was 17.6% for patients with acute respiratory distress syndrome.
Conclusions:
Acute respiratory distress syndrome is a severe early complication of pneumonectomy with a poor outcome. The low survival underlines the need for novel management strategies.
