FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

ABSTRACT

SESSION TITLE Pneumothorax, Chylothorax, and Pleural Effusion Case Posters SESSION TYPE Case Report Posters PRESENTED ON 10/17/2022 1215 pm - 0115 pm INTRODUCTION: An alveolopleural fistula (APF) is a pathological communication between the pulmonary alveoli and the pleural space. If pneumothorax persists beyond five days, it is labeled as a prolonged air leak (PAL). Herein, we present a patient with respiratory failure, spontaneous pneumothorax with persistent air leak resulting in functional pneumonectomy despite CTS intervention. CASE PRESENTATION A 60-year-old female with PMH of diabetes, hypertension was initially admitted for right lower extremity cellulitis. About ten days into the admission, patient started becoming progressively hypoxic and was noted to be saturating 82% on room air with crackles noted bilaterally. A CT angiogram showed findings suggestive of multifocal pneumonia. Covid-19 pneumonia was initially suspected despite negative testing and a course of remdesivir and steroids was administered. All other infectious workup returned negative. Patient's oxygenation requirements worsened over the next two weeks eventually requiring intubation. Bronchoscopy with bronchoalveolar lavage showed growth of stenotrophomonas and patient received a course of trimethoprim-sulfamethoxazole. Patient was subsequently extubated and transitioned to high flow nasal cannula. Two weeks later, she developed acute respiratory deterioration due to a right sided pneumothorax requiring emergent pigtail placement and subsequent intubation. She was noted to have a persistent airleak from the chest tube and imaging showed a persistent pneumothorax with possible malpositioning of the chest tube. Despite repositioning of the previous chest tube and a second chest tube insertion, patient's PAL persisted and she underwent video assisted thoracoscopic surgery (VATS) that showed a large bronchopleural fistula emanating from the right upper and middle lobes requiring stapling and surgical pleurodesis. Bronchoscopy prior to VATS did not show any signs of obstruction. Due to prolonged intubation, she underwent tracheostomy placement followed gradually by chest tube removal when no air leak was appreciated. After the removal of the chest tube, her lung gradually formed multiple bullae with no functional residual lung. Despite this, her respiratory status stabilized and she was discharged to a LTACH. DISCUSSION: The likely cause of APF here was the emergent chest tube insertion. APF and PALs are most seen following pulmonary resection or biopsy but can also be seen following spontaneous pneumothorax or traumatic chest tube insertions. Although an endobronchial valve was entertained, the lung damage was extensive enough to have no change in patient's outcome. CONCLUSIONS: Our case demonstrates a rare but complicated hospital course of a patient where a chest tube insertion resulted in non-resolving APF with PAL despite therapeutic interventions in an unfortunate case of "functional pneumonectomy". Underlying pneumonia may have also contributed to the APF resulting in PAL. Reference #1 1. Liberman M, Muzikansky A, Wright CD, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010;89891. Reference #2 2. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg 2006;82197. Reference #3 3. Rivera C, Bernard A, Falcoz PE, et al. Characterization and prediction of prolonged air leak after pulmonary resection a nationwide study setting up the index of prolonged air leak. Ann Thorac Surg 2011;921062. DISCLOSURES No relevant relationships by Mohammed Halabiya No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel