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Original Article

Spontaneous Pneumothorax in the Native Lung After Single Lung Transplantation

Starobin, Daniel MD*; Rubin, Amihai MD; Yellin, Alon MD; Fink, Gershon MD*; Kramer, Mordechai R MD*

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doi: 10.1097/01.lab.0000131032.65780.39
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Abstract

Single lung transplantation is considered a standard procedure for end-stage lung disease as lung emphysema or idiopathic pulmonary fibrosis. The 1-, 3- and 5-year survival rates are 90%, 70%, and 50%, respectively. Commonly, the native lung does not cause any morbidity and mortality in most cases.1–3

Spontaneous pneumothorax of native lung is a rare complication after single lung transplantation (SLT).

We present 4 cases of posttransplantation native lung pneumothorax as well as previously published cases; we summarized data from literature sources in which full reports were available.

CASE REPORTS

Case No. 1

A 38-year-old male patient with idiopathic pulmonary fibrosis (IPF) underwent left lung transplantation in 1994. The patient received immunosuppression consisted of azathioprine, cyclosporine, and prednisone. Progressing dyspnea with chronic rejection was diagnosed 32 months after transplantation. Lung function tests recorded then were: FEV1 43.8%, FVC 38.5%, TLC 33.1%, and RV 35.2%. Rest O2 saturation was 90% in room air.

He was admitted at the 36th posttransplant month as a result of dyspnea. Right lung (native) pneumothorax was found on chest x-ray. He was treated successfully with chest tube drainage for 6 days.

The bronchiolitis obliterans was accompanied by gradual deterioration of lung function tests (FEV1 dropped to 28%) and the patient died 56 months posttransplantation.

Case No. 2

A 48-year-old male patient with emphysema underwent left lung transplantation in 1992. He was treated with cyclosporine, azathioprine, and prednisone. He was admitted 90 months after transplantation because of right lung (native lung) pneumothorax. Pneumothorax was treated with chest tube drainage but right pneumonectomy was required for persistent air leak.

Chronic rejection was diagnosed at the same time. Lung function tests decreased from FEV1 70% to 25%. Immunosuppression after he was diagnosed with bronchiolitis obliterans syndrome was changed to FK506, azathioprine, and prednisone; however, the patient died of respiratory failure 108 months after transplantation.

Case No. 3

A 40-year-old male patient underwent right lung transplantation as a result of emphysema in 1997. During his childhood, he underwent left lower lobe lobectomy as a result of foreign body aspiration. The posttransplantation period was complicated by acute rejection with gradually worsened lung function tests (FEV1 18–21%, FVC 31%, TLC 36%). He was treated with cyclosporine, azathioprine, and prednisone.

Left lung (native lung) pneumothorax, which developed 3 months after transplantation, was treated successfully by chest tube drainage for 5 days. The patient died suddenly out of the hospital 6 months after transplantation. No autopsy was performed.

Case No. 4

A 52-year-old male patient with emphysema secondary to heavy smoking underwent left lung transplantation. The postoperative period was unremarkable but the patient returned to smoking. He was treated with cyclosporine, azathioprine, and prednisone.

The patient developed right lung (native lung) spontaneous pneumothorax twice, at 72 and 74 months after lung transplantation. The patient was treated with a chest tube in the first episode and pleurodesis with talc slurry was successfully applied in the second episode.

The patient is now 94 months posttransplantation and has stable lung function tests (FEV1 45%, FVC 38%, TLC 101%, RV 228%).

DISCUSSION

We described 4 cases of spontaneous pneumothorax of the native lung after single lung transplantation. In 3 cases, pneumothorax was treated successfully with a chest tube; in 1, pneumonectomy was needed for the management of a persistent air leak. Primary lung disease was emphysema in 3 patients and IPF in 1. Two patients died of progressive chronic rejection; 1 had an unexplained sudden death. One patient is well 8 years posttransplantation (Table 1).

Table 1
Table 1:
Cases of Native Lung Pneumothorax After SLT*

In 3 cases presented in the literature, no patient had bronchiolitis obliterans.

Native lung pneumothorax was treated successfully by chest tube in one case,1 by videothoracoscopic (VATS) bullectomy in another one,2 and pneumonectomy as a result of a persistent leak in a third case.3 No influence on mortality was found in these 3 patients.

Herridge et al4 did not find any influence of pleural complications after SLT on mortality, although incidence of these complications was 22% in their observed group of 138 patients. Pneumothorax was the most frequent complication, almost 50% of the complicated cases. Thirty percent of pneumothoraces developed after transbronchial biopsy, and most pneumothorax episodes happened in an allograft.4

Mal et al5 investigated the morbidity and mortality related to the native lung in SLT for emphysema. Seventy four percent of reported 46 emphysema patients survived perioperative period. Almost half of them died during 4 years of follow up. Only one death was related to native lung: this patient died of bacterial pneumonia. Other deaths were caused by allograft problems: mostly chronic rejection: bronchiolitis obliterans syndrome (BOS) or infective complications. Native lung hyperinflation was a frequent finding in these patients but pneumothorax developed only in 2 patients.5

In another report in 36 SLT patients, various complications occurred in the early postoperative period (up to 6 weeks) in 50% of patients. Only 1 patient, however, had pneumothorax of native lung that needed pneumonectomy for continuous leak and died of sepsis later. Four cases of pneumothorax registered in the late posttransplantation period. They were treated successfully by chest tube alone (1 case), thoracoscopic wedge resection and pleurodesis (2 cases), and pneumonectomy (1 case). No influence of native lung pneumothorax on mortality was found in this study as well.6

Patients with lymphangioleiomyomatosis (LAM) are prone to spontaneous pneumothorax pre- or posttransplantation. Native lung pneumothorax developed in 3 of 8 patients with LAM during the postoperative period after SLT.7 Patients with pulmonary LAM are at higher risk for intraoperative pneumothorax.8 During follow up, after 27 patients with LAM who underwent SLT, 6 spontaneous pneumothorax episodes happened; 5 of them needed chest tube insertion alone and 1 resolved without invasive intervention.9

Few studies of native lung hyperinflation were published in the last decade. Weill et al10 have registered symptomatic acute (during 1 month posttransplantation) native lung hyperinflation (ANLH) in approximately 15% from the group of 51 post-SLT patients with emphysema. Patients with ANLH had longer ventilator support and hospital stay times but no effect on FEV1, 6-minute walk test, rejection rate, infection, BOS, and survival was found. The increased incidence of symptomatic ANLH was observed mostly in the patients with bullous emphysema.10

Patients with acute or chronic native lung hyperinflation are prone to spontaneous native lung pneumothorax.

Hyperinflation of native lung could have a deleterious effect on allograft function. Total lung capacity of transplanted lung decreased significantly after SLT in the study by Estenne et al.11 Malchow and coworkers followed 32 patients with emphysema after SLT; 50% incidence of postoperative lung hyperinflation was found. Patients with native lung hyperinflation had lower FEV1 and a worse outcome.12

The influence of lung volume reduction surgery (LVRS) on the natural history of patients with native lung hyperinflation was reported. Results of these studies were contradictory; on 1 site, Shulman et al13 concluded that LVRS did not improve outcome, chronic rejection rate, or chronic native lung hyperinflation incidence in patients with emphysema after SLT. On the other hand, Anderson et al14 and Kroshus et al15 found that LVRS of native lung after SLT in patients with emphysema were beneficial in these patients’ symptoms and lung function tests. Native lung spontaneous pneumothorax after SLT is related to the primary lung disease: native lung hyperinflation in the patients with emphysema, pulmonary fibrosis, cystic changes, bronchiectasis, and LAM.

In summary, spontaneous native lung pneumothorax after SLT is not an uncommon early and late posttransplantation complication. Native lung spontaneous pneumothorax after SLT is more common in patients with lung emphysema, LAM, and BOS. Native lung hyperinflation is probably the main cause of native lung pneumothorax in patients with emphysema. Most native lung pneumothoraces resolve spontaneously or with a chest tube; others need VATS bullectomy or open surgery. LVRS could be considered as an optional treatment.

REFERENCES

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Keywords:

single lung transplantation (SLT); native lung pneumothorax; lung emphysema; idiopathic pulmonary fibrosis (IPF); bronchiolitis obliterans syndrome

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