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HYPERBARIC OXYGEN THERAPY FOR REFRACTORY VANISHING BRONCHUS SYNDROME AFTER LUNG TRANSPLANTATION

      TOPIC: Transplantation
      TYPE: Medical Student/Resident Case Reports
      INTRODUCTION: Lung transplantation (LTx) is an evolving field. Post-LTx complications including airway stenosis, anastomotic infection, granulation tissue formation, and airway dehiscence remain a source of increased morbidity, mortality, and costs. We present here a case of non-anastomotic bronchial stenosis with a critical narrowing of bronchus intermedius, presenting as ongoing shortness of breath and an acute drop in pulmonary function tests (PFTs).
      CASE PRESENTATION: A 59-year-old bilateral LTx recipient presented 5 months after LTx with worsening shortness of breath associated with an acute drop in PFTs with an obstructive pattern. Bronchoscopy revealed a yellow mucoid pseudomembrane bilaterally with narrowing of bronchus intermedius in the right-middle lobe and the right-lower lobe, requiring balloon dilation and placement of a stent in the right-middle lobe. Follow-up PFTs improved, yet did not fully recover to baseline. Hyperbaric oxygen therapy was initiated with a dramatic improvement of his shortness of breath and further improvement of his PFTs.
      DISCUSSION: Herein we discuss a case of vanishing bronchus syndrome (VBS) in an LTx recipient that was successfully treated with airway stenting and hyperbaric oxygen therapy. VBS occurs in approximately 3% of LTx recipients and typically evolves slowly [1]. The complication is thought to be caused by ischemic injury as bronchial anastomosis in LTx is devoid of direct blood supply. Revascularization of bronchial circulation through collaterals usually requires 3-4 weeks, during which time the risk of airway ischemia is ample.
      CONCLUSIONS: VBS is a very serious airway complication that can be exceedingly difficult to manage. The complication requires early recognition and treatment. Hyperbaric oxygen therapy may improve outcomes in these patients.
      REFERENCE #1: Kshettry VR, Kroshus TJ, Hertz MI, Hunter DW, Shumway SJ, Bolman RM III. Early and late airway complications after lung transplantation: incidence and management. Ann Thorac Surg. 1997. June; 63 6: 1576- 1583.
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