Respiratory distress following pneumonectomy.

A 60-year-old man was referred to the thoracic surgery service with a large mass in the right upper lobe of his lung. He had a 4-week history of productive cough and hemoptysis. A chest radiograph was obtained after antibiotic therapy failed to resolve the symptoms. He had no history of weight loss, fevers, or chest pain. He had smoked until 2 years prior and had an 80 pack-year history of cigarette use. A physical examination revealed no bone pain or lymphadenopathy. A CT scan of the chest demonstrated a 9-cm solid mass in the right upper lobe closely adherent to the right hilum. Bronchoscopy with brush biopsy of the mass revealed non-small cell cancer that was confirmed with bronchial washings. A CT scan of the head was negative for metastatic disease. A cervical mediastinoscopy was negative for metastatic lymphadenopathy and was followed immediately by a right pneumonectomy with mediastinal lymph node dissection. The right mainstem bronchus was closed with staples (TA-30 Autosuture; United States Surgical Corporation; Norwalk, CT) with a leg length of 4.8 mm and a closed height of 2.0 mm. A pleural patch was placed over the staple line. The patient was extubated in the operating room, and he did well in the immediate postoperative period. A new onset of atrial fibrillation was treated with digoxin and was converted to normal sinus rhythm on postoperative day 4. The final pathology revealed moderately differentiated adenocarcinoma (10 cm by 7.5 cm), with negative bronchial margins and one hilar node (station 11) positive. Lymphovascular invasion was identified, as well as multifocal acute necrotizing, organizing pneumonia. After 1 week, a chest radiograph showed a rising fluid level within the right chest cavity, (Fig 1) with a serum WBC count of 10 3 10/mL. On postoperative day 9, the patient experienced a sudden onset of tachypnea and dyspnea. He expectorated copious amounts of serosanguinous sputum. A physical examination revealed coarse breath sounds over the left