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Year : 2023  |  Volume : 3  |  Issue : 2  |  Page : 66-67

Air–Fluid level in the chest X-Ray after pneumonectomy

Department of Respiratory Medicine, A.J. Institute of Medical Sciences and Research Centre, Mangaluru, Karnataka, India

Date of Submission29-Oct-2022
Date of Acceptance28-Nov-2022
Date of Web Publication02-May-2023

Correspondence Address:
Dr. Vishnu Sharma Moleyar
Department of Respiratory Medicine, A.J. Institute of Medical Sciences and Research Centre, Kuntikana, Mangaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jalh.jalh_34_22

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How to cite this article:
Moleyar VS, Jacob JJ. Air–Fluid level in the chest X-Ray after pneumonectomy. J Adv Lung Health 2023;3:66-7

How to cite this URL:
Moleyar VS, Jacob JJ. Air–Fluid level in the chest X-Ray after pneumonectomy. J Adv Lung Health [serial online] 2023 [cited 2023 May 28];3:66-7. Available from: https://www.jalh.org//text.asp?2023/3/2/66/375537

A 46-year-old female had left pneumonectomy for a tumor in the left main bronchus. Her postoperative period was uneventful. She was extubated 6 h after surgery. She was off oxygen within 24 h of surgery. She was recovering well, being mobilized. She had no fever, cough, sputum, or any other respiratory symptoms. She had no history of any other lung or systemic diseases. A follow-up chest X-ray was taken 10 days after the surgery [Figure 1].
Figure 1: The chest X-ray PA view taken 10 days after surgery

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Question: What is the most likely diagnosis?

  1. Postpneumonectomy pyopneumothorax
  2. Postpneumonectomy hemopneumothorax
  3. Postpneumonectomy stump dehiscence with bronchopleural fistula (BPF)
  4. Normal postpneumonectomy air–fluid level
  5. Infection of the pleural space by gas-producing organism.

Answer: 4-Normal postpneumonectomy air–fluid level.

The chest X-ray shows the shift of the mediastinum to the left side (trachea and cardiac both shifted). Fundic gas shadow is higher up, which is an indirect sign of elevated left dome of the diaphragm. There is a slight reduction in the volume of the left hemithorax. These changes, in the absence of any symptom, indicate postpneumonectomy normal air–fluid level in the left pleural space.[1]

Air–fluid level in an otherwise asymptomatic patient indicates postpneumonectomy fluid collection which settles over a period of time. Immediately after pneumonectomy, the pleural space will be filled with air. After a day, fluid starts accumulating in the pleural space, usually at a rate of one or two intercostal spaces per day.[1] After 2–3 weeks, most of the air in the pleural space will be replaced by fluid.

Other causes for air–fluid level in the chest X-ray following pneumonectomy include stump dehiscence leading to BPF, infection of the pleural space (pyopneumothorax/empyema), and rarely, infection of the pleural space by gas-producing organisms.[2] In these instances, the patient will be symptomatic. The presence of fever, malaise, increasing breathlessness, cough, and chest pain indicates infection of the pleural space. The patient may become toxic with the features of sepsis if infection is severe.[2] In case of stump dehiscence, the patient may have copious expectoration. Hypoxia, chest wall tenderness, and edema may be present in these cases. The chest X-ray may show rapidly increasing air–fluid level and shift of the mediastinum to the opposite, which never occurs in a normal postpneumonectomy air–fluid collection.[3] Other lung may be involved (pneumonia) in patients with BPF.

Postpneumonectomy stump dehiscence is more common following right pneumonectomy.[4] Prolonged intubation, infection, malignancy, associated obstructive airway disease, and small stump are associated with a higher risk of stump dehiscence. Postpneumonectomy empyema is more common following resection of infected lung.

Postpneumonectomy hemopneumothorax is a rare complication.[5] It usually occurs within 24–48 h following surgery. Worsening dyspnea, hypotension, pallor, and drainage of excess blood from the intercostal tube suggest this complication.[6] In such cases, coagulation abnormalities/bleeding disorders should be ruled out. An immediate exploration and ligation of bleeding vessels may be required in some cases, if conservative treatment with blood transfusion, correction of the underlying cause if any, and symptomatic measures fail.

When doubt exists in the postoperative cases with air–fluid level, thoracic ultrasound can be helpful.[7] The presence of debris, floaters, and multiple thick loculations may indicate infection. Whenever the pleural space infection is suspected in the postoperative period, diagnostic aspiration and pleural fluid analysis should be done to rule out empyema.

This patient made an uneventful recovery. The chest X-ray 6 months after pneumonectomy showed the resolution of air–fluid level [Figure 2].
Figure 2: The chest X-ray PA view taken 6 months after surgery

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Munden RF, O'Sullivan PJ, Liu P, Vaporciyan AA. Radiographic evaluation of the pleural fluid accumulation rate after pneumonectomy. Clin Imaging 2015;39:247-50.  Back to cited text no. 1
Kopec SE, Irwin RS, Umali-Torres CB, Balikian JP, Conlan AA. The postpneumonectomy state. Chest 1998;114:1158-84.  Back to cited text no. 2
Christiansen KH, Morgan SW, Karich AF, Takaro T. Pleural space following pneumonectomy. Ann Thorac Surg 1965;1:298-304.  Back to cited text no. 3
Hollaus PH, Setinek U, Lax F, Pridun NS. Risk factors for bronchopleural fistula after pneumonectomy: Stump size does matter. Thorac Cardiovasc Surg 2003;51:162-6.  Back to cited text no. 4
Harmon H, Fergus S, Cole FH. Pneumonectomy: Review of 351 cases. Ann Surg 1976;183:719-22.  Back to cited text no. 5
Wahi R, McMurtrey MJ, DeCaro LF, Mountain CF, Ali MK, Smith TL, et al. Determinants of perioperative morbidity and mortality after pneumonectomy. Ann Thorac Surg 1989;48:33-7.  Back to cited text no. 6
Lesser TG. Significance of chest ultrasound in the early postoperative period following thoracic surgery. J Thorac Dis 2019;11 Suppl 3:S352-3.  Back to cited text no. 7


  [Figure 1], [Figure 2]


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