One-Lung Ventilation in a Patient With Necrotizing Pneumonia Complicated by a Bronchopleural Fistula.

Abstract

A 32-year-old male with morbid obesity presented to the emergency department with a one-week history of shortness of breath and productive cough. This patient had previously been evaluated at an urgent care facility, diagnosed with pneumonia, and prescribed oral antibiotics. This patient's worsening shortness of breath and productive cough led this patient to seek further care at the emergency department. Chest radiography revealed acute respiratory distress syndrome (ARDS) with an empyema in the right pleural space. He was admitted to the intensive care unit and subsequently intubated due to severely compromised cardiopulmonary function. The patient then underwent irrigation of the chest cavity and chest tube placement for drainage of the right-sided empyema. Surgical cultures revealed growth of Streptococcus anginosus and appropriate antibiotics were started. The patient's pulmonary function continued to deteriorate and this patient was placed on venous to venous extracorporeal membrane oxygenation (VV ECMO). Due to continued respiratory failure and a persistent air leak, a double-lumen endotracheal tube (DLT) was exchanged to initiate one-lung ventilation (OLV) to optimize ventilation and protect the lung containing the empyema. Over the following days, worsening leukocytosis and atelectasis were noted upon imaging prompting cardiothoracic surgery to return to the operating room to perform a right posterolateral thoracotomy and full right lung decortication. The procedure was successful and a bronchopleural fistula (BPF) was observed, secondary to the necrotizing pneumonia. The observation of the fistula explained the persistent air leak and issues maintaining adequate oxygenation. OLV through a DLT was continued over the following days, and the patient's pulmonary status and leukocytosis ultimately began to improve over the next two weeks. This patient was then able to be weaned off the EMCO device and was extubated. The patient was stabilized and discharged to a rehabilitation facility for further recovery. This case highlights how the use of lung isolation techniques were essential in the recovery of this patient with an estimated 50% mortality rate due to significant pulmonary injury from necrotizing pneumonia and complicated by a BPF.

• Authors: Kellen T Creech, Umar Chaudhry
• Journal: Cureus (Cureus) Vol. 13 Issue 5 Pg. e15138 (May 20 2021) ISSN: 2168-8184 [Print] United States
• PMID: 34164241 (Publication Type: Case Reports)
• Copyright: Copyright © 2021, Creech et al.