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(Chest. 1999;116:1131-1133.)
© 1999 American College of Chest Physicians

Contralateral Tension Pneumothorax Following Unilateral Chest Tube Drainage of Bilateral Pneumothoraces in a Heart-Lung Transplant Patient*

Y.C. (Gary) Lee, MBChB; Gregory B. McGrath, MBBS; Weng S. Chin, MBBS and Richard W. Light, MD, FCCP

* From the Department of Respiratory Medicine (Drs. Lee, McGrath, and Chin), Sir Charles Gairdner Hospital, Perth, Australia; and the Division of Pulmonary Medicine (Drs. Lee and Light), St. Thomas Hospital and Vanderbilt University, Nashville, TN.

Correspondence to: Richard W. Light, MD, FCCP, Department of Pulmonary Medicine, St. Thomas Hospital, 4220 Harding Road, Nashville TN 37202; e-mail: rlight98{at}yahoo.com


   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 References
 
Bilateral pneumothoraces can result from unilateral air leak after heart-lung transplantation. The recommended initial management of such patients is insertion of a unilateral chest tube. We report a patient who developed bilateral pneumothoraces after undergoing transbronchial biopsies 2 years after a heart-lung transplant. The unilateral chest tube failed to drain the contralateral pneumothorax and a tension pneumothorax developed. The advocated approach should be used with caution.

Key Words: heart-lung transplant • pneumothorax • transbronchial biopsy


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 References
 
After a heart-lung transplantation, the normal anterior barriers between the pleural cavities are interrupted.1 Simultaneous bilateral pneumothoraces from a unilateral air leak and rapid shifting of the accumulated air between the two hemithoraces, although rare, are potential complications of a persisting interpleural communication.2 It has been recommended that a single chest tube is sufficient for the drainage of bilateral pneumothoraces in this group of patients.3

We report one patient who developed bilateral pneumothoraces 2 years after her heart-lung transplant. The unilateral chest tube insertion failed to drain the contralateral pneumothorax and instead resulted in the radiologic picture of a tension pneumothorax.


   Case Report
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 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 20-year-old white woman received a heart-lung transplant in October 1996 for congenital heart disease and resultant pulmonary hypertension. Postoperatively, she suffered an episode of acute rejection (grade A3), which responded to augmented steroid therapy. In the following 2 years, she had several episodes of respiratory tract infections from various organisms including cytomegalovirus, Staphylococcus aureus, and Cryptococcus. These were successfully treated with appropriate antimicrobial therapies. She had two episodes of grade A2 acute lung graft rejections during that period; both were treated successfully with augmented steroid therapy with restoration of baseline lung functions.

In September 1998, she developed dyspnea and her FEV1 dropped from her usual level of 2.2 L to 1.7 L. Bronchoscopy demonstrated bronchitic changes, and transbronchial biopsies showed no evidence of rejection. She developed a small right-sided pneumothorax following the procedure, which resolved spontaneously. Her FEV1 improved to 2.0 L after treatment with IV antibiotics.

Two months later, she developed a flu-like illness and presented again with dyspnea and a productive cough. Her FEV1 was again reduced to 1.6 L. Bronchoscopy performed on this occasion demonstrated inflamed mucosae and thick purulent secretions. A culture of bronchial washings grew a zygomycetes-like fungi with branching filaments as well as Pseudomonas aeruginosa. Multiple transbronchial biopsies taken from the right middle and lower lobes showed no evidence of acute rejection.

A chest radiograph performed 4 h after the bronchoscopy demonstrated small bilateral pneumothoraces (Fig 1 ). She was asymptomatic. A second radiograph 3 h later showed an increase in size of the bilateral pneumothoraces, and the patient developed tachypnea and desaturation on room air (from 95 to 89%). Since the transbronchial biopsies from the right lung were the most likely cause of the air leak, a chest tube was inserted into the right hemithorax.



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  		Figure 1. Bilateral pneumothoraces following transbronchial biopsies to right lower lobe (lung edges indicated by arrows).

 
This provided minimal relief of symptoms despite continual bubbling through the right chest tube, and suction at 30 cm H2O was initiated. A repeat chest radiograph 2 h afterwards showed complete resolution of the right pneumothorax (Fig 2 ). However, the left pneumothorax had increased in size with tension effect and significant mediastinal shift to the right. The patient remained tachypneic and hypoxemic. Her BP was stable at 120/80, and her heart rate was 100/min. A second chest tube was inserted into the left hemithorax. A significant amount of air was released on insertion of the tube, and this was associated with dramatic relief of dyspnea.



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  		Figure 2. A chest radiograph taken after the insertion of a right-sided chest tube shows an increase in size of the left pneumothorax with a mediastinal shift toward the right.

 
A further chest radiograph the following morning revealed resolution of the left pneumothorax but reappearance of the right one. Both chest tubes remained patent. Over the next few days, there was radiologic evidence of a "shifting pneumothorax" between the two hemithoraces, which eventually resolved without further intervention. She received a 6-week course of amphotericin B for her fungal infection.


   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
References
 
The anterior pleural reflections are severed during heart-lung transplantation and occasionally after other cardiac surgery performed via median sternotomy. The resultant interpleural communication allows air or fluid to move between the pleural cavities. The development of bilateral pneumothoraces can be potentially life-threatening if it is under tension.1 Successful treatment with single chest tube drainage in some cases has led some to advocate this as the standard management of bilateral pneumothoraces in heart-lung transplant recipients.3

In the case of this patient, the development of bilateral pneumothoraces following right-sided transbronchial biopsies and the subsequent "shifting pneumothoraces" confirmed that the communication between the two hemithoraces had persisted.

Single chest tube drainage failed to evacuate the accumulated air in the contralateral hemithorax and resulted in a potentially life-threatening tension pneumothorax. It is possible that the persistent anterior mediastinal communication was small and that the rapid drainage of the unilateral pneumothorax drew the adjacent scar tissue and adhesions together, thereby producing a valve-like effect and preventing drainage of the contralateral hemithorax.

Two small retrospective series reported that bilateral or shifting pneumothoraces occurred in 33 to 40% of heart-lung transplant recipients. In a retrospective study of heart-lung transplant patients after the immediate postoperative period, 6 out of 72 patients developed bilateral pneumothoraces.3 Two of the six patients were managed conservatively, two were unstable requiring urgent bilateral chest tube placement, and the remaining two were treated successfully with unilateral chest tube drainage.

Engeler et al2 reported that eight of 25 postoperative heart-lung transplant patients had either shifting pneumothoraces or decompression of pneumothoraces by contralateral chest tube, which is indicative of open communication of both hemithoraces. However, it is uncertain whether the anterior mediastinal defect would persist1 or whether it would eventually be bridged by postoperative scar tissues.2 Our patient demonstrated that an interpleural defect may remain patent for > 2 years after transplantation and therefore, is likely to be permanent.

Physicians should be aware that in heart-lung transplant patients, communication between both hemithoraces may be permanent. Bilateral pneumothoraces often develop from a unilateral air leak. Although a single chest tube may be adequate, this approach should be taken with care because the contralateral pneumothorax may not always be adequately drained, and potentially life-threatening tension pneumothorax may result.

Received for publication April 13, 1999. Accepted for publication June 2, 1999.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

  1. Judson, MA, Sahn, SA (1996) The pleural space and organ transplantation. Am J Respir Crit Care Med 153,1153-1165[Abstract]
  2. Engeler, CE, Olson, PN, Engeler, CM, et al (1992) Shifting pneumothorax after heart-lung transplantation. Radiology 185,715-717[Abstract/Free Full Text]
  3. Paranjpe, DV, Wittich, GR, Hamid, LW, et al (1994) Frequency and management of pneumothoraces in heart-lung transplant recipients. Radiology 190,255-256[Abstract/Free Full Text]



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