Commentary: Cut it out: Posttraumatic pneumonectomy and pleural contamination after impalement.

Marvi Tariq, MD, and Benjamin Wei, MD

Posttraumatic pneumonectomy is often an unavoidable consequence of major lung trauma, with high rate of postoperative complications requiring therapeutic adjuncts such as VV-ECMO and serial washouts.

See Article page 275.

Less than 1.3% of penetrating chest traumas require lung resection; however, those that do suffer from greater morbidity and mortality based on extent of resection. While lung-sparing resections are preferred, injuries involving major hilar or bronchial structures and severely devitalized lung tissue often necessitate a more anatomic resection such as a pneumonectomy. Posttraumatic pneumonectomy is considered a last resort due to high mortality rates, which are often quoted as >50%. Patients who survive an emergent pneumonectomy often suffer from greater rates of postoperative pulmonary edema, acute respiratory distress syndrome (ARDS), right heart failure, and empyema.

Here, Freeman and colleagues discuss a compelling case of posttraumatic pneumonectomy where the extent of parenchymal devitalization and major bronchial injury precluded any attempts at lung salvage. The patient's impalement with a fence had led to traumatic transection of right middle and lower lung lobes, transection of the right superior pulmonary vein, and significant inferior carinal injury requiring complex tracheoplasty and venovenous extracorporeal membrane oxygenation (VV-ECMO). The authors provide a highly detailed description of the events during triage, evaluation, and the operation, demonstrating the outstanding planning and clutch performance of the patient's care team during this highly unusual emergency.

Critical to the patient's survival in this case was the use of VV-ECMO. In patients postpneumonectomy who develop ARDS, VV-ECMO has indeed been shown to be a feasible salvage therapy that allows for protective ventilation. VV-ECMO is also useful in patients with traumatic tracheal injury by protecting the tracheal repair from barotrauma. Freeman and colleagues used VV-ECMO for management of hypoxia due to severe pulmonary contusions and large-volume resuscitation as well as protection of the carinal repair from high airway pressures and high levels of positive end-expiratory pressure that would have potentially been necessary if only mechanical ventilation was employed postoperatively. It is possible that the use of ECMO prevented postoperative ARDS development in the patient's remaining lung, which can be fatal in up to 50% of pneumonectomy cases. Fortunately for everyone involved, the calculated gamble to use VV-ECMO (and avoid potentially problematic anticoagulation) rather than veno-arterial ECMO paid off, as the patient's right heart dysfunction resolved within roughly 2 weeks.

Another consequence of penetrating lung trauma with pleural cavity contamination is empyema. Notoriously difficult to treat, empyema has historically been treated with open or portovac drainage, with newer strategies involving radical debridement and serial packing of the chest cavity with iodine-soaked gauze until macroscopically clean. The latter strategy was successfully used by Freeman and colleagues with 6 serial washouts and packing. The chest was closed after each washout to allow early patient mobilization and rehabilitation in the intensive care unit.

Overall, this is an exceptional case involving successful management of severe lung injury with posttraumatic pneumonectomy and demonstrates the appropriate use of VV-ECMO and serial washouts as adjuncts for management of associated postoperative complications. Quite simply, the surgical team needed to get everything right in the care of this patient to get a favorable outcome: from the technical performance of a carinal reconstruction to the prescient use of VV-ECMO to the more mundane and laborious tasks of chest washout and application of negative pressure wound therapy. The clear-eyed, systematic manner in which they approached the situation make for an incredible story and “save.”