Spontaneous Contralateral Pneumothorax in a Patient With Remote History of Pneumonectomy

Abstract

Introduction: Pneumothorax (PTX) in patients that underwent pneumonectomy is a life-threatening condition and challenging to manage. The incidence is 0.3% to 1.2% and overall mortality rate is reported to be about 50%. Since pneumonectomy is not common, clinicians rarely encounter such cases. We present a case of secondary spontaneous PTX (SSP) in a patient with remote history of pneumonectomy. CASE PRESENTATION: A 59 year-old-male with history of Non-Small Cell Lung Cancer involving all 3 lobes of the right lung (right pneumonectomy and chemotherapy in 2008), HIV (on anti-retrovirals, CD4 count 455) and COPD presented to the emergency department (ED) with worsening shortness of breath and chest tightness for 1 day and cough productive of white phlegm for a few days. He denied fever, chills, trauma, sick contacts or recent travel. In the ED, he saturated at 98% on room air, had labored breathing, but spoke in full sentences. He was placed on 100% non-rebreather oxygen therapy. Breath sounds were decreased over the left lung field. Labs were unremarkable. Chest X-ray (CXR) revealed a moderate PTX with no additional mediastinal shift in comparison to prior films, and surgical evidence of prior right pneumonectomy. The patient was admitted to the intensive care unit (ICU) and a 14Fr pigtail catheter was placed into the left pleural space. The patient quickly stabilized. Subsequent CXRs showed resolution of the PTX. CT chest revealed complete re-expansion of the left lung. Medical chemical pleurodesis was done to prevent PTX recurrence. The patient had an uneventful recovery and was discharged home. DISCUSSION: Management of SSP in patients that have undergone pneumonectomy is challenging, given the reduced respiratory reserve and risk of PTX recurrence. Initial recommendations for treatment of SSP in patients with prior pneumonectomy include high flow oxygen and placement of a chest tube. Once stabilized, it is standard of care to perform an intervention to prevent PTX recurrence. Multiple case reports describe surgical interventions (surgical pleurodesis or stapling of blebs) performed to prevent PTX recurrence in patients with SSP. These procedures are risky in patients with prior pneumonectomies and require surgical expertise that is not always available. We opted for a nonsurgical chemical pleurodesis as a less invasive alternative to prevent PTX recurrence. Our patient is clearly at risk for PTX recurrence. However, he did tolerate the initial PTX well, and the subsequent chemical pleurodesis will reduce his chance of a recurrence without exposing him to a higher risk surgical procedure. Conclusions: SSP in patients with prior pneumonectomy requires prompt treatment and preventative measures, either surgical or medical, to avoid recurrence. We opted for medical chemical pleurodesis, the lower risk approach.