*From the Department of Respiratory Medicine (Drs. Lee, McGrath, and Chin), Sir Charles Gairdner Hospital, Perth, Australia; and the Division of Pulmonary Medicine (Drs. Lee and Light), St. Thomas Hospital and Vanderbilt University, Nashville, TN.
Correspondence to: Richard W. Light, MD, FCCP, Department of Pulmonary Medicine, St. Thomas Hospital, 4220 Harding Road, Nashville TN 37202; e-mail: email@example.com
Bilateral pneumothoraces can result from unilateral air leak after
heart-lung transplantation. The recommended initial management of such
patients is insertion of a unilateral chest tube. We report a patient
who developed bilateral pneumothoraces after undergoing transbronchial
biopsies 2 years after a heart-lung transplant. The unilateral
chest tube failed to drain the contralateral pneumothorax and a tension
pneumothorax developed. The advocated approach should be used with
a heart-lung transplantation, the normal anterior barriers between the
pleural cavities are interrupted.1Simultaneous bilateral
pneumothoraces from a unilateral air leak and rapid shifting of the
accumulated air between the two hemithoraces, although rare, are
potential complications of a persisting interpleural
communication.2It has been recommended that a single
chest tube is sufficient for the drainage of bilateral pneumothoraces
in this group of patients.3
We report one patient who developed bilateral pneumothoraces 2 years
after her heart-lung transplant. The unilateral chest tube insertion
failed to drain the contralateral pneumothorax and instead resulted in
the radiologic picture of a tension pneumothorax.
A 20-year-old white woman received a heart-lung transplant in
October 1996 for congenital heart disease and resultant pulmonary
hypertension. Postoperatively, she suffered an episode of acute
rejection (grade A3), which responded to augmented steroid therapy. In
the following 2 years, she had several episodes of respiratory tract
infections from various organisms including cytomegalovirus,
Staphylococcus aureus, and Cryptococcus. These were
successfully treated with appropriate antimicrobial therapies. She had
two episodes of grade A2 acute lung graft rejections during that
period; both were treated successfully with augmented steroid therapy
with restoration of baseline lung functions.
In September 1998, she developed dyspnea and her
FEV1 dropped from her usual level of 2.2 L to 1.7
L. Bronchoscopy demonstrated bronchitic changes, and transbronchial
biopsies showed no evidence of rejection. She developed a small
right-sided pneumothorax following the procedure, which resolved
spontaneously. Her FEV1 improved to 2.0 L after
treatment with IV antibiotics.
Two months later, she developed a flu-like illness and presented again
with dyspnea and a productive cough. Her FEV1 was
again reduced to 1.6 L. Bronchoscopy performed on this occasion
demonstrated inflamed mucosae and thick purulent secretions. A culture
of bronchial washings grew a zygomycetes-like fungi with branching
filaments as well as Pseudomonas aeruginosa. Multiple
transbronchial biopsies taken from the right middle and lower lobes
showed no evidence of acute rejection.
A chest radiograph performed 4 h after the bronchoscopy
demonstrated small bilateral pneumothoraces (Fig 1
). She was asymptomatic. A second radiograph 3 h later showed an
increase in size of the bilateral pneumothoraces, and the patient
developed tachypnea and desaturation on room air (from 95 to 89%).
Since the transbronchial biopsies from the right lung were the most
likely cause of the air leak, a chest tube was inserted into the right
This provided minimal relief of symptoms despite continual bubbling
through the right chest tube, and suction at 30 cm
H2O was initiated. A repeat chest radiograph
2 h afterwards showed complete resolution of the right
pneumothorax (Fig 2
). However, the left pneumothorax had increased in size with tension
effect and significant mediastinal shift to the right. The patient
remained tachypneic and hypoxemic. Her BP was stable at 120/80, and her
heart rate was 100/min. A second chest tube was inserted into the left
hemithorax. A significant amount of air was released on insertion of
the tube, and this was associated with dramatic relief of
A further chest radiograph the following morning revealed resolution of
the left pneumothorax but reappearance of the right one. Both chest
tubes remained patent. Over the next few days, there was radiologic
evidence of a “shifting pneumothorax” between the two hemithoraces,
which eventually resolved without further intervention. She received a
6-week course of amphotericin B for her fungal infection.
The anterior pleural reflections are severed during heart-lung
transplantation and occasionally after other cardiac surgery performed
via median sternotomy. The resultant interpleural communication allows
air or fluid to move between the pleural cavities. The development of
bilateral pneumothoraces can be potentially life-threatening if it is
under tension.1 Successful treatment with single chest
tube drainage in some cases has led some to advocate this as the
standard management of bilateral pneumothoraces in heart-lung
In the case of this patient, the development of bilateral
pneumothoraces following right-sided transbronchial biopsies and the
subsequent “shifting pneumothoraces” confirmed that the
communication between the two hemithoraces had persisted.
Single chest tube drainage failed to evacuate the accumulated air in
the contralateral hemithorax and resulted in a potentially
life-threatening tension pneumothorax. It is possible that the
persistent anterior mediastinal communication was small and that the
rapid drainage of the unilateral pneumothorax drew the adjacent scar
tissue and adhesions together, thereby producing a valve-like effect
and preventing drainage of the contralateral hemithorax.
Two small retrospective series reported that bilateral or shifting
pneumothoraces occurred in 33 to 40% of heart-lung transplant
recipients. In a retrospective study of heart-lung transplant patients
after the immediate postoperative period, 6 out of 72 patients
developed bilateral pneumothoraces.3 Two of the six
patients were managed conservatively, two were unstable requiring
urgent bilateral chest tube placement, and the remaining two were
treated successfully with unilateral chest tube drainage.
Engeler et al2 reported that eight of 25 postoperative
heart-lung transplant patients had either shifting pneumothoraces or
decompression of pneumothoraces by contralateral chest tube, which is
indicative of open communication of both hemithoraces. However, it is
uncertain whether the anterior mediastinal defect would
persist1or whether it would eventually be bridged by
postoperative scar tissues.2 Our patient demonstrated that
an interpleural defect may remain patent for > 2 years after
transplantation and therefore, is likely to be permanent.
Physicians should be aware that in heart-lung transplant patients,
communication between both hemithoraces may be permanent. Bilateral
pneumothoraces often develop from a unilateral air leak. Although a
single chest tube may be adequate, this approach should be taken with
care because the contralateral pneumothorax may not always be
adequately drained, and potentially life-threatening tension
pneumothorax may result.
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