Idiopathic postpneumonectomy pulmonary edema: Hyperinflation of the remaining lung is a potential etiologic factor, but the condition can be averted by balanced pleural drainage
Alvarez, J. M., Tan, J., Kejriwal, N., Ghanim, K., Newman, M. A. J., Segal, A., et al. (2007). Idiopathic postpneumonectomy pulmonary edema: Hyperinflation of the remaining lung is a potential etiologic factor, but the condition can be averted by balanced pleural drainage. Journal of Thoracic and Cardiovascular Surgery, 133(6), 1439-1447.
Objectives: Idiopathic postpneumonectomy pulmonary edema is a leading cause of mortality after pneumonectomy. Postoperative hyperinflation of the remaining lung is an etiologic factor. We have demonstrated avoidance of postpneumonectomy pulmonary edema solely by changing management of the pneumonectomy space to a balanced drainage system. In sheep, we tested the following hypothesis: (1) Postoperative induced hyperinflation of the remaining lung can cause postpneumonectomy pulmonary edema. (2) A balanced drainage system can prevent its development.
Methods: We performed 37 right-sided pneumonectomies in adult sheep. In experiment 1, after surgery, 10 sheep had continuous suction (5 kPa) applied through an intercostal catheter placed in the empty hemithorax to induce mediastinal shift and hyperinflation of the left lung without adverse hemodynamic sequelae. In experiment 2, 27 sheep were randomly allocated into 3 equal groups regarding management of the residual empty right hemithorax: balanced drainage, no intercostal drainage, and clamp-release intercostal underwater drainage. A fourth group of 9 sheep served as a sham controls placebo with the same anesthetic and a right thoracotomy.
Results: All sheep tolerated surgery without adverse event. In experiment 1, there was significant mediastinal shift at necropsy in all sheep and 60% (n = 6) had postpneumonectomy pulmonary edema develop in the left lung (P = .023 vs sham). In experiment 2, incidences of postpneumonectomy pulmonary edema were as follows: 0 in balanced group (P = .057 vs other groups), 3 (30%) in no-drainage group, and 3 (30%) in clamp–release group. Only the 12 sheep with postpneumonectomy pulmonary edema had respiratory distress; the rest had uneventful recoveries.
Conclusion: In a sheep model of postpneumonectomy pulmonary edema, hyperinflation from mediastinal shift is an etiologic factor. A balanced drainage system averts postpneumonectomy pulmonary edema. This is the first time such a causal relationship has been demonstrated, supporting our continued use of balanced drainage after pneumonectomy.