History of Present Illness
A 62-year-old Caucasian female patient presented to the emergency room with new-onset sputum production, fatigue, and fever. Chest radiography showed air–fluid level in the left thoracic cavity ( Fig. 13.1 ).
Past Medical History
The patient was a former smoker (20 cigarettes a day; 35 pack-years). She stopped smoking 8 years before the current episode, when she had been diagnosed with non–small cell lung cancer and underwent left upper lobectomy with mediastinal radical lymphadenectomy. Seven years after that surgery, the patient had undergone left completion pneumonectomy for hemoptysis caused by aspergilloma. Chronic obstructive pulmonary disease (COPD) had been also diagnosed, with moderate airway obstruction, and a long-acting muscarinic agent (tiotropium Respimat 2.5 μg, two inhalations in the morning) was ordered. However, the patient did not take it regularly.
Physical Examination and Early Clinical Findings
Upon arrival at the hospital, the patient was alert and oriented but appeared cachectic, pale, and fatigued. She was febrile (body temperature 38.1° C [100.58° F]) and had a blood pressure of 96/62 mm Hg, heart rate of 107 beats/min, respiratory rate of 25 breaths/min, and oxygen saturation of 86% at pulse oximeter. Arterial blood gas (ABG) analysis in room air showed normal pH (7.39), hypoxemia (partial pressure of oxygen [Pa O 2 ] 55.4 mm Hg), slight hypercapnia (partial pressure of carbon dioxide [Pa CO 2 ] 47.2 mm Hg), and rise of bicarbonate (HCO 3 − 28 mEq/L). Respiratory examination revealed absence of breath sounds on the left side of the chest and no pathological findings on the right side. Cardiovascular examination was unremarkable. The abdomen was soft, without distension or ascites.
Diagnostic laboratory workup for infection showed a marked elevation of inflammatory parameters (serum C-reactive protein [CRP] 296 mg/L; normal values < 5 mg/L) and leukocytosis (white blood cell [WBC] count 10,700 cells/μL, neutrophils 87%). Lactate was slightly increased (2 mmol/L).
Clinical Course
The patient initially received 50% oxygen supplement via a Venturi mask and obtained oxygen saturation (SpO 2 ) of 98%. According to the pulmonologist’s recommendation, supplemental oxygen was reduced to 3 L/min administered via a nasal cannula, and SpO 2 of 92% to 94% was maintained.
Intravenous fluid therapy with a crystalloid solution (Ringer’s lactate solution [RLS] 60 mL/hr) was initiated, in addition to intravenous antibiotics (piperacillin/tazobactam 4.5 g every 8 hours, vancomycin 500 mg every 6 hours, and levofloxacin 750 mg once a day). Blood cultures were obtained before antibiotics were administered. A urinary catheter was placed to monitor urine output. After checking for hemodynamic stability, the patient was admitted to the thoracic surgery unit.
The suspicion of a fistula between the left bronchial stump and the pneumonectomy space was confirmed with chest computed tomography (CT) ( Fig. 13.2 ) and bronchoscopy ( Fig. 13.3 ).
Posterolateral thoracotomy was performed the day after admission, and loculated, smelly pleural effusion was found intraoperatively. After extensive debridement of the necrotic and fibrous infected tissue, the left thoracic cavity was irrigated with saline. Because of the short stump, a direct closure or shortening of the left main bronchus was not possible. Thus the thoracic surgeons decided to use the omentum as a patch. Short upper laparotomy was performed, and the omentum was dissected from the stomach along the greater curvature and released from the transverse colon and mesocolon. Through a small incision of the diaphragm, the omentum was placed in the left thoracic cavity. It was then sutured on the bronchial wall with five interrupted sutures. To ensure a tension-free flap, the omentum was fixed to the mediastinal pleura. At the end of the procedure, the surgeons packed the left thoracic cavity with four gauzes impregnated with povidone-iodine solution. Then a chest tube was inserted and the thoracotomy temporarily closed. Continuous suction of 5 mm Hg was applied through the chest tube. The patient was extubated in the operating room and transferred to the intermediate care unit. The antiseptic packing was changed on the second and fourth postoperative days. On postoperative day 6, the operative field was macroscopically clean; therefore the clinicians decided to fill the cavity with 1 L of saline, which also contained 0.3 of netilmicin, 2.2 g of amoxicillin/clavulanic acid, 1 g of vancomycin, and 0.4 g of fluconazole. The patient was discharged from the hospital 15 days after surgery.
