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Allergy and Airway |

Postpneumonectomy Syndrome, an Unusual Complication

Muhammad Rizwan, MD; Khawaja Rahman, MD; Zeeshan Ahmad, MD; Zia Rehman, MD; Abid Butt, MD
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East Carolina University, Greenville, NC


Chest. 2013;144(4_MeetingAbstracts):49A. doi:10.1378/chest.1703617
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Abstract

SESSION TITLE: Airway Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Postpneumonectomy syndrome (PPS) is a very rare complication of pneumonectomy with incidence of 1 in 640 cases. It results from an excessive mediastinal shift and rotation producing symptomatic airway and esophageal stretching and compression. Because of rarity of condition diagnosis can be missed as in our case.

CASE PRESENTATION: 66 year old male with past medical history of COPD on home oxygen, HTN, CHF and carcinoid tumor s/p right pneumonectomy about 15 years ago, presented to ER with shortness of breath. He had exertional dyspnea for about 2 years and had multiple admissions to different hospitals for same. He complained of orthopnea, leg swelling and dry cough. He was an ex smoker and had a 30 pack year smoking history. On examination patient had crackles at left base and trace leg edema. Labs were unremarkable except for hemoglobin of 10.9 g/dl and BNP of 540 pg/ml. Chest X-ray showed complete opacification of right hemithorax, right mediastinal shift and mild diffuse prominence of pulmonary interstitium on the left. Patient was admitted with working diagnosis of congestive heart failure exacerbation and possible bronchial obstruction. On echocardiogram his EF was 45%. CT scan of the chest showed moderate mediastinal shift to the right; left main stem bronchus stenosis, likely from extrinsic compression. A diagnosis of postpneumonectomy syndrome (PPS) was proposed. PFTs revealed FEV1of 34% predicted and FEV1/FVC ratio was 60. Diagnosis was confirmed with fiberoptic bronchoscopy, which showed that left main stem bronchus was compressed from posterior to anterior; and past this, all segmental orifices were widely patent. CT surgery consult was obtained, but patient declined any surgical intervention and was discharged to home.

DISCUSSION: PPS commonly presents with progressive dyspnea,ocassionally has stridor and heartburn. Onset of symptoms is between 6 months to 29 years after surgery. Female gender, young age at surgery and right sided pneumonectomy are common risk factors. Diagnosis is confirmed with CT chest and fiberoptic bronchoscopy. It is commonly treated with repositioning of mediastinum with saline solution-filled prosthesis with good results.

CONCLUSIONS: Our objective of presenting this case is to enhance awareness of this entity amongst physicians, to enable early recognition of PPS, and to minimize potentially preventable patient morbidity and mortality.

Reference #1: Valji AM, Maziak DE, Shamji FM, Matzinger FR. Postpneumonectomy syndrome: recognition and management. Chest. 1998 Dec; 114(6): 1766-9.

Reference #2: Shen KR, Wain JC, Wright CD, Grillo HC, Mathisen DJ. Postpneumonectomy syndrome: surgical management and long-term results. J Thorac Cardiovasc Surg. 2008 Jun; 135(6): 1210-6; discussion 1216-9. doi:10.1016/j.jtcvs.2007.11.022.

Reference #3: Soll C, Hahnloser D, Frauenfelder T, Russi EW, Weder W, Kestenholz PB. Clinical presentation and treatment. Eur J Cardiothorac Surg. 2009 Feb; 35(2):319-24. doi: 10.1016/j.ejcts.2008.07.070. Epub 2008 Nov 21.

DISCLOSURE: The following authors have nothing to disclose: Muhammad Rizwan, Khawaja Rahman, Zeeshan Ahmad, Zia Rehman, Abid Butt

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