Early Post-Transplant Persistent Pneumothorax, Dehiscence or No Dehiscence?

Introduction Early pleural complications following lung transplantation (LT) are common, ranging from 22-34%. Persistent air leaks early after transplant have been associated with increased post-operative mortality. They can result from airway complications such as anastomosis dehiscence or from a peripheral communication between the lung and the pleura. Case Report A 66-year-old female with end stage hypersensitivity pneumonitis and a prior episode of right pneumothorax was admitted to the hospital with worsening hypoxemic respiratory failure. She was found to have a new right pneumothorax which improved following chest tube insertion. She was listed for LT and remained hospitalized until a donor become available. Routine bronchoscopy preformed on POD 2, prior to extubation, showed no evidence of airway ischemia. On POD 6, worsening bilateral pneumothorax with severe subcutaneous emphysema were observed on chest X ray as well as a new air leak on the right sided chest tube. CT chest demonstrated grossly intact anastomosis; however, air was seen approximating the right anastomotic site raising concern for dehiscence. An additional chest tube was inserted with no improvement. Bronchoscopy demonstrated intact anastomoses with no airway ischemia reperfusion injury, however, an open RUL accessory bronchus was noted to take off from the native trachea (Figure 1A). A 6 mm Spiration endobronchial valve was deployed at the accessory RUL bronchus (Figure 1B) with resolution of the air-leak and pneumothorax, and subsequent chest tube removal. Summary Tracheal bronchus is a known bronchial anomaly, prevalence ranging from 0.1- 2%. Persistent air leak early after transplantation raises concern for airway complications. Albeit rare, the possibility of tracheal tree abnormalities, should be considered, especially in a stable well oxygenated patient. Intrabronchial valve placement can yield good results avoiding further invasive intervention in this highly immunosuppressed population.