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Introduction. Post-pneumonectomy bronchopleural fistula is a seri- ous complication of lung surgery, with an incidence of. 0.8% to 12.1%.1 Furthermore, there is ...
690247 research-article2017

PRF0010.1177/0267659117690247PerfusionMarek et al.

Case Report

Extracorporeal membrane oxygenation in the management of post-pneumonectomy air leak and adult respiratory distress syndrome of the non-operated lung

Perfusion 2017, Vol. 32(5) 416­–418 © The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/0267659117690247 DOI: 10.1177/0267659117690247 journals.sagepub.com/home/prf

Szkorupa Marek,1 Simek Martin,2 Zuscich Ondrej,2 Chudacek Josef,1 Neoral Cestmir1 and Lonsky Vladimir2

Abstract 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 adult respiratory distress syndrome (ARDS) of the non-operated lung. Established veno-venous extracorporeal membrane oxygenation (VV ECMO) was utilized to maintain tissue oxygenation while re-do surgery was performed. The leaking bronchial stump was closed with an azygos vein patch and, subsequently, weaning off ECMO was accomplished 7 days later. The patient fully recovered and he is limited only by mild exertional dyspnea at 24 months follow-up after the initial surgery. Keywords pneumonectomy; air leak; ARDS; ECMO

Introduction Post-pneumonectomy bronchopleural fistula is a serious complication of lung surgery, with an incidence of 0.8% to 12.1%.1 Furthermore, there is considerable risk of respiratory failure due to bronchopneumonia or acute lung injury (ALI)/adult respiratory distress syndrome (ARDS) of the non-operated lung.2 Efforts to maintain sufficient tissue oxygenation and/or CO2 elimination require mechanical ventilation, mostly of an aggressive nature, which further worsens the bronchial air leak and alveolo-capillary membrane inflammatory damage (barotrauma).1 Although the reported incidence of ARDS after pneumonectomy varies between 1% and 8.6%, the mortality rate related to this complication ranges from 43% to 85%.2

Case report A 68-year-old male with carcinoma of the right lower pulmonary lobe invading the hilum underwent a right extended pneumonectomy with stapler-dissected bronchial stump. Spinocellular cancer was confirmed histologically (grade 2, pT3 pN1 pM0) and the immediate

postoperative course was apparently uneventful. However, on the 8th 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 nonoperated left lung. An inter-costal drain was inserted into the right hemothorax, but neither permanent air leakage nor methylene blue, bronchoscopically introduced into the right bronchial stump, was detected in the chest tube (Figure 1). “Mixed” respiratory failure (pH 6.9, pCO2 20 kPa, pO2 7.4 kPa, lactate 6.8 mmol/l, PaO2/ FiO2 79) with hemodynamic compromise prompted the need for aggressive mechanical ventilation (Pressure 11st

Department of Surgery, University Hospital Olomouc, Olomouc, Czech Republic 2Department of Cardiac Surgery, University Hospital Olomouc, Olomouc, Czech Republic Corresponding author: Simek Martin, Department of Cardiac Surgery, University Hospital Olomouc, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic. Email: [email protected]

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without tumor or infection recurrence. He is only limited by mild exertional dyspnea and has regularly attended follow-ups within the 24 months after the pneumonectomy.

Discussion

Figure 1.  Chest X-ray showing homogenous infiltrates (ARDS) of the non-operated lung and inserted inter-costal drain into the right chest post-pneumonectomy cavity.

Control Ventilation, peak inflation pressure [PIP] 35 cm H20, f 12/min positive end expiratory pressure [PEEP] 15 cm H20, FiO2 0.75) and catecholamine support. Despite maximum respiratory support and a mediumto-high dose of norepinephrine (0.8 µg/kg/min), the patient continued to deteriorate and VV femoral-jugular high-flow ECMO (PLS system™, Maquet, Hirrlingen, Germany) was percutaneously established with normalization of blood gases and pH within the first four hours. Subsequently, mechanical ventilation was set on the level of protective ventilation (tidal volume 6 ml/kg, 5 cmH2O of PEEP) and catecholamine support was weaned off. However, the following day, methylene blue was detected in the chest drain and bronchoscopy confirmed complete bronchial stamp dehiscence. Re-do surgery was performed on full-flow ECMO support (pump flow 6.0 l/min, FiO2 0.7, gas flow 5.2 l/min) 6 hours later when a reduced unfractionated heparin dose (30–50 IU/kg/h) led to the near-normal activated partial thromboplastin time (aPTT) value (40–50 s). Respiratory support within surgery was achieved by applying only a PEEP valve to the endotracheal tube. The dehiscent bronchial stump was hand sewn and buttressed with an azygos vein patch. The post re-do surgery course was uneventful, with a total of 400 ml blood loss. Subsequently, the patient was successfully weaned off ECMO on the 16th POD and was extubated one day later (a total of 7 days of ECMO support). He was discharged home on the 35th POD, but he was readmitted 6 weeks later because of post-pneumonectomy empyema. No bronchopleural fistula was proved; however, the empyema had to be treated with a thoracostomy, negative pressure wound therapy and serratus muscle flap advancement. Currently, the patient is clinically stable

ECMO is an effective option for CO2/O2 exchange, independent of alveolo-capillary membrane function. It may reverse the detrimental effect of tissue hypoxia/ acidosis or malperfusion and protect the lungs against aggressive mechanical ventilation-associated injury.3 Because extracorporeal membrane O2 exchange is more flow-dependent than CO2 removal, full-flow, pump-driven VV ECMO is vital for hypoxic (Type I) respiratory failure, whereas hypercapnic (Type II) respiratory failure might be managed with either lowflow, pump-driven VV ECMO or with a pumpless extracorporeal pump assist circuit (pECLA).3 Severe hemodynamic instability or concomitant heart failure need to be managed with veno-arterial (VA) or VAV ECMO to avoid end-organ malperfusion and hypoxemia.3 A recently published meta-analysis did not show any superiority of ECMO over conventional ventilation for ARDS management.4 On the other hand, in an animal post-pneumonectomy ARDS model, ECMO and protective ventilation achieved a significantly better outcome compared to conventional treatment.5 Thus, in this scenario, ECMO would be a promising therapeutic option for viral pneumonitis or traumarelated lung injury, as had been reported.4 In patients with hypercapnic (Type II) respiratory failure, the effectiveness of pECLA treatment has been described, particularly when stump insufficiency is allowed to be managed conservatively with chest drainage and endoscopic fibrin sealant closure.6 In the case of hypoxemic respiratory failure or the need for support while surgical management of fistula is performed, full-flow VV ECMO ought to be established.7 The successful use of ECMO in the surgical management of postpneumonectomy ALI/ARDS or severe bronchopneumonia of the non-operated lung has been sporadically reported.7,8 However, a recently published survey across high-volume thoracic centers confirmed a 67% to 75% mortality rate of severe ARDS after lung resection surgery, despite established ECMO programs.9 Thus, the mortality rate of this complication remains high, even through increasing availability and experience with ECMO support.

Conclusion Post-pneumonectomy air leak and severe respiratory failure related to ARDS of the non-operated lung is

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uncommon, but a life-threatening complication of lung surgery. In our case, the established VV ECMO guaranteed sufficient oxygenation/CO2 removal, it allowed surgical bronchial leak management and it provided time for lung recovery. Acknowledgement The authors are grateful to Ms. Carmen Francis, MD and Mr. Pavel Homola, MD for their editing work on the manuscript.

Declaration of Conflicting Interest The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Supported by the institutional research development program (FNOL RVO 2015).

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Perfusion 32(5) 3. Park PK, Napolitano LM, Bartlett RH. Extracorporeal membrane oxygenation in adult acute respiratory distress syndrome. Crit Care Clin 2011; 27: 627–646. 4. Munshi L, Telesnicki T, Walkey A, et  al. Extracorporeal life support for acute respiratory failure. A systematic review and meta-analysis. Ann Am Thorac Soc 2014; 11: 802–810. 5. Iglesias M, Jungebluth P, Petit C, et  al. Extracorporeal lung membrane provides better lung protection than conventional treatment for severe postpneumonectomy noncardiogenic acute respiratory distress syndrome. J Thorac Cardiovasc Surg 2008; 135: 1362–1371. 6. Hommel M, Deja M, von Dossow V, et  al. Bronchial fistulae in ARDS patients: management with an extracorporeal lung assist device. Eur Respir J 2008; 32: 1652–1655. 7. Fica M, Suarez F, Aparicio R, Suarez C. Single site venovenous extracorporeal membrane oxygenation as an alternative to invasive ventilation in post-pneumonectomy fistula with acute respiratory failure. Euro J CardioThorac 2012; 41: 950–952. 8. Dünser M, Hasibeder W, Rieger M, et al. Successful therapy of severe pneumonia-associated ARDS after pneumonectomy with ECMO and steroids. Ann Thorac Surg 2004; 78: 335–337. 9. Rinieri P, Peillon C, Bessou JP, et al. National review of use of extracorporeal membrane oxygenation as respiratory support in thoracic surgery excluding lung transplantation. Eur J Cardio-Thorac Surg 2015; 47: 87–94.