title: Managing the pneumonectomy space after extrapleural pneumonectomy: postoperative intrathoracic pressure monitoring.
abstract: OBJECTIVE
  Rapid fluid evacuation of the pneumonectomy space can cause ipsilateral mediastinal shift, contralateral lung hyperexpansion, compromised caval blood return and a precipitous drop in cardiac output. Conversely, rapid fluid accumulation can cause contralateral mediastinal shift with compression of the remaining lung and respiratory insufficiency. In this retrospective analysis, we evaluate the efficacy of intrathoracic pressure monitoring and intermittent fluid aspiration to manage the pneumonectomy space in the early postoperative period following extrapleural pneumonectomy.
  
  
  METHODS
  Prior to chest closure, a 14 F Rob-Nel catheter was placed in the pneumonectomy space and connected to pressure tubing to monitor ipsilateral intrathoracic pressure continuously. Central venous pressure monitoring and serial chest X-rays were performed according to usual intensive care routine. Pneumonectomy space fluid was aspirated intermittently when there was increase in intrathoracic pressure, refractory hypotension, mediastinal shift on chest X-ray, or clinical decline. Postoperative imaging was re-evaluated retrospectively for confirmation of mediastinal shift by a senior radiologist.
  
  
  RESULTS
  From January to December 2008, 47 patients underwent extrapleural pneumonectomy for pleural mesothelioma (median age 65 years with range 34-79 years, 77% male). Twenty (43%) patients had left-sided disease and 32 (68%) received local heated intra-operative cisplatin-based chemotherapy. The median baseline pneumonectomy space pressure was 3 cm H(2)O (range: -6 to +12). The median amount of fluid withdrawn over the first 2 days postoperatively was 300 cc (range: 0-1980 cc). Thirty-one (69%) patients had minimal, if any, change in mediastinal position during the first 2 postoperative days with intermittent drainage performed when the pneumonectomy space pressure rose. Eleven (25%) patients had increasing contralateral shift, four of whom had return of the mediastinum to baseline during this time period. The median fluid drained from the four patients whose contralateral shift resolved was 290 cc (range: 220-800 cc) compared to 200 cc (range: 150-480 cc) from the seven patients whose contralateral shift remained, but this difference did not reach significance (p=0.365).
  
  
  CONCLUSIONS
  Intrathoracic pressure monitoring may be used as a guide for intermittent fluid evacuation of the pneumonectomy space prior to onset of clinical signs or symptoms, to avoid the cardiopulmonary risks of rapid fluid removal. Contralateral mediastinal shift should be treated with incremental drainage when there is a rise in intrathoracic pressure to prevent cardiovascular complications.
authors.affiliation: Division of Thoracic Surgery and Department of Radiology, Brigham and Women's Hospital, Boston, MA 02215, USA. awolf2@partners.org
authors.forename: Andrea S
authors.initials: AS
authors.lastname: Wolf
authors.forename: Francine L
authors.initials: FL
authors.lastname: Jacobson
authors.forename: Tamara R
authors.initials: TR
authors.lastname: Tilleman
authors.forename: Yolonda
authors.initials: Y
authors.lastname: Colson
authors.forename: William G
authors.initials: WG
authors.lastname: Richards
authors.forename: David J
authors.initials: DJ
authors.lastname: Sugarbaker
mesh_terms: D000328:Adult; D000368:Aged; D000970:Antineoplastic Agents / Q000627:therapeutic use; D002496:Central Venous Pressure; D017024:Chemotherapy, Adjuvant; D002945:Cisplatin / Q000627:therapeutic use; D005260:Female; D006801:Humans; D008297:Male; D008654:Mesothelioma / Q000188:drug therapy / Q000601:surgery*; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods; D010997:Pleural Neoplasms / Q000188:drug therapy / Q000601:surgery*; D011013:Pneumonectomy / Q000009:adverse effects*; D011182:Postoperative Care / Q000379:methods; D012189:Retrospective Studies; D013396:Suction
chemical_list: D000970:Antineoplastic Agents; D002945:Cisplatin