D104-02 Pneumonectomy as a Salvage Therapy for Refractory Acute Respiratory Distress Syndrome

Abstract Introduction Influenza A infections, while typically benign, can cause significant end-organ and/or secondary infectious complications. Cases causing life-threatening disease often require utilization of invasive therapies. Case Presentation A previously healthy 16-year-old female presented to the ED with progressive confusion and respiratory distress after recently testing positive for influenza A at urgent care and attempting at-home supportive care. On arrival, she was febrile, hypotensive, and hypoxemic consistent with septic shock and acute hypoxemic respiratory failure. Her chest X-ray was concerning for superimposed consolidative pneumonia (Figure 1A), and her respiratory culture grew methicillin-susceptible Staphylococcus aureus (MSSA). She required intubation, vasoactive support, and transfer to the pediatric intensive care unit. There, she developed refractory hypoxemia despite FiO2 1.0, with CT imaging confirming progression to acute respiratory distress syndrome (ARDS), and she was initiated on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Her course was complicated by right-greater-than-left necrotizing MSSA pneumonia and right hemothorax. Repeat attempts to wean respiratory and VV-ECMO support were unsuccessful, requiring tracheostomy placement and evaluation and listing for bilateral lung transplantation. Serial imaging demonstrated the development of severe, predominantly right-sided bronchiectasis and consolidation (Figure 1B), with nearly 2:1 left versus right lung perfusion on perfusion scan (Figure 1C). Given her asymmetric disease burden, a right pneumonectomy was performed. Within one week, she was successfully decannulated from VV-ECMO. Her tracheostomy was removed 14 months after placement without requiring further supplemental oxygen or eventual lung transplantation. Discussion This case highlights pneumonectomy as a potential salvage therapy in asymmetric, refractory ARDS. We postulated that the more affected right lung was acting as a persistent inflammatory nidus, sustaining ARDS shunt physiology and systemic inflammation. Surgical removal of severely damaged lung tissue has been shown to reduce inflammatory burden and allow for lung recovery. Furthermore, this patient’s differential perfusion study allowed for targeting the more affected lung for removal. Pneumonectomy is traditionally reserved for malignancy or trauma but may serve as a definitive therapy in select cases. For non-malignant indications such as this patient’s prolonged inflammatory injury and subsequent bronchiectasis, pneumonectomy is primarily utilized as a bridge to transplant to mitigate interim complications. However, removal of the more damaged right lung facilitated recovery of the contralateral lung, enabling ECMO decannulation and ICU discharge without progressing to transplantation. There are minimal data on pneumonectomy’s therapeutic role aside from as a bridge to transplant, but this patient’s course suggests other potential indications, such as ameliorating refractory ARDS. This abstract is funded by: None