Postoperative Pneumothorax

5 May
2011

Postoperative Pneumothorax

An 80-year-old retired male railroad worker was referred for evaluation of a chronic cough and a persistent left lower lobe infiltrate. One month prior to presentation, he was hospitalized for a pneumonia and a parapneumonic effusion. Thoracentesis at that time yielded sterile fluid with negative cytologic findings. He complained of progressive dyspnea, worse at night. He denied fevers, chills, sweats, pedal edema, wheezing or chest pain. Though he initially lost over 6.8 kg (15 pounds), he had regained 2.3 kg (5 pounds) since prior hospitalization. He had pneumonia 58 years earlier, but has otherwise been free of pulmonary or cardiac problems. As a youth, he had tuberculosis of his right thumb and scrofula of his neck; both were resected. He has a 60-pack history, and continued to smoke one-half a pack of cigarettes per day up until admission. There was no other additional risk factor for carcinoma, either social or occupational.

Physical examination revealed a cachetic, elderly white man who was in mild respiratory distress with 30 breaths per minute. Head and neck examination revealed a 1.2 cm basal cell carcinoma at his right external auditory canal. There was no lymphadenopathy. His chest moved symmetrically with inspiration and expiration. Percussion revealed dullness of the lower two-thirds of his left chest posteriorly. Breath sounds were markedly decreased over this same area. Cardiac auscultation revealed distant heart sounds with systolic murmur compatible with aortic stenosis. Results from the remainder of his examination were unremarkable.

FIGURE 1

Bronchoscopy revealed an obstructing endobron­chial lesion of his left lower lobe distal to the superior bronchial orifice. Pulmonary function studies dem­onstrated an FEV, of 1.2 L. Ventilation/perfusion lung scan demonstrated no perfusion or ventilation to the left lower lung. Endobronchial biopsy specimens re­vealed a squamous cell carcinoma. Based on the aforementioned data, he was a candidate for lobectomy but not pneumonectomy. He was then referred to the thoracic surgery department and underwent left lower lobectomy. levitra professional

The patient did well and was extubated within 24 hours. During the first postoperative day, he had significant bloody drainage from his chest tubes. This decreased over the ensuing days and his tubes were removed. On the sixth postoperative day, he developed mild shortness of breath without fever or leukocytosis. A chest roentgenogram (Fig 1) showed a subsegmental atelectatic left upper lobe and an air fluid level in the left side of his chest.

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