UpToDate - Pneumonectomy

Question 1

Pneumonectomy is most commonly performed for what disease process?

Answer 1

Bronchogenic carcinoma, when the tumor is at the mainstem bronchus or the proximal bronchus intermedius, adjacent to the right upper lobe orifice, or when the tumor extends across a major fissure.

Often, if the tumor is not too extensive, you can find a way to resect hilar masses w/ reconstruction of the hilar structures. Always determine complete resectability before making committing moves.

Question 2

What changes do you expect in the post-pneumonectomy space?

Answer 2

Elevation of the hemidiaphragm, replacement of air with fluid, hyperinflation of the remaining lung, shifting of the mediastinum towards the PPS.

Question 3

How long does complete opacification of the pneumonectomy space take?

Answer 3

Approximately 4 months.

Question 4

What if there is rapid accumulation of fluid in the postpneumonectomy space?
What complications are you most worried about/what is your ddx?

Answer 4

Concern for hemorrhage, infection, or chylothorax.

Question 5

A patient s/p L pneumonectomy has indication for thoracentesis. Since they are s/p pneumonectomy, will this make it easier?

Answer 5

No. The diaphragm is raised, and the heart rotates counterclockwise into the vacant space. You may hit the heart or spleen.

The same issues occur on the right side.

Question 6

How can severe shifting of the mediastinal structures affect the airway after pneumonectomy?

Answer 6

Narrowing and stretching of the main bronchus -> obstruction of the remaining lung.

Question 7

When you resect a lung, how much do you expect lung volume, FEV1, and DLCO to fall?

Answer 7

Overexpansion of the other lung means the decrease of these parameters is usually <50%.

Question 8

Postpneumonectomy pulmonary edema: frequency, left vs right, characteristics?
Prophylaxis?
Mortality?

Answer 8

• overall frequency of 2 to 5 percent
• three times more common following RIGHT than left pneumonectomy
• thought to represent a form of the acute respiratory distress syndrome (ARDS); characterized clinically by respiratory distress and hypoxemia within 72 hours of surgery
• single intraoperative dose of Solu-Medrol (250 mg administered just prior to ligation of the pulmonary artery) may decrease the risk of developing this complication
• mortality rates exceed 50 percent