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Obstructive Lung Diseases |

Asymmetrical Acute Respiratory Distress Syndrome Associated With Asymmetric Lung Perfusion

Eduardo Martinez, MD; Masooma Niazi, MD; Gilda Diaz-Fuentes, MD; Sindhaghatta Venkatram, MD
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Bronx-Lebanon Hospital Center, New York, NY


Chest. 2015;148(4_MeetingAbstracts):752A. doi:10.1378/chest.2266889
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Abstract

SESSION TITLE: Obstructive Lung Disease Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Acute respiratory distress syndrome (ARDS) usually presents with bilateral lung opacities and refractory hypoxemia. Causes of ARDS are extensive and include sepsis, pneumonia, aspiration, pancreatitis, transfusions, and drugs. (1) Asymmetric ARDS is rare and has been described after lung resection, trauma, and re-expansion. (2) We present a patient with septic shock and unilateral DAD.

CASE PRESENTATION: 73 year-old woman admitted with dyspnea and fatigue of 2 days duration. Medical history included squamous lung carcinoma treated with left lower lobectomy, chemo/radiation therapy. On exam she was tachypneic and hypoxic (SatO2 85%). Laboratory: leukocytosis (WBC 31,000k/ul). Chest- x-ray: diffuse right lung infiltrates with volume loss of the left lung. Chest CT revealed right lung infiltrates; left lung volume loss and hilar vascular distortion.(Fig 1) She required mechanical ventilation for moderate ARDS (PaO2/FiO2 153) and shock. Cardiac etiologies were ruled out. Right lung transbronchial biopsy showed diffuse alveolar damage (DAD).(Fig 2) A chest CT from a month prior showed similar changes without infiltrates. Lung perfusion scan confirmed decreased perfusion to the left lung. She was treated for septic shock and pneumonia, she improved and was liberated from ventilator after 7 days after hospital admission.

DISCUSSION: Asymmetrical ARDS is a rare presentation of non-cardiogenic pulmonary edema described in patients after pneumonectomy, lobectomy or chest trauma. (2) The main force that regulates the lung’s fluid balance is the microvascular pressure, primarily in the capillaries. Pulmonary blood flow directly affects this pressure. In ARDS, there are increases in the dispersion of both pulmonary blood flow and alveolar ventilation because vascular and bronchial functions are altered by inflammatory mediators. As perfusion is central to the pathogenesis of ARDS, we postulate that our patient developed asymmetrical right DAD as a consequence of poor perfusion to left lung that resulted from prior lobectomy and radiation therapy.

CONCLUSIONS: ARDS should be considered in the differential diagnosis of unilateral diffuse infiltrates. Prior lung surgery and possible radiation could increase the risk of this condition.

Reference #1: Epidemiology of acute lung injury and acute respiratory distress syndrome. Frutos-Vivar F et al. 2006, Seminars in Respiratory and Critical Care Medicine, pp. 327-336

Reference #2: Asymmetric ARDS following pulmonary resection: CT findings initial observations. Padley SP et al. 2002. Radiology, pp. 468-473

DISCLOSURE: The following authors have nothing to disclose: Eduardo Martinez, Masooma Niazi, Gilda Diaz-Fuentes, Sindhaghatta Venkatram

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