Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Sequelae and complications of pneumonectomy

Scott E Kopec, MD
Richard S Irwin, MD
Section Editor
James K Stoller, MD, MS
Deputy Editor
Helen Hollingsworth, MD


Pneumonectomy, or surgical removal of an entire lung, is performed most frequently for management of bronchogenic carcinoma. In this setting, pneumonectomy is required over lesser resection, such as lobectomy, when the tumor is located in a main stem bronchus or the proximal bronchus intermedius, adjacent to the right upper lobe orifice, or when the tumor extends across a major fissure [1]. Pneumonectomy may rarely be performed for pulmonary metastases or for a variety of benign diseases, such as inflammatory lung disease (eg, pulmonary tuberculosis, fungal infections, and bronchiectasis), traumatic lung injury, congenital lung disease, and bronchial obstruction with a destroyed lung [2].

Pneumonectomy is associated with a variety of reasonably predictable anatomic changes, significant decrements in pulmonary function, and a number of potential complications that involve the respiratory system, the cardiovascular system, and the pleural space [3] (table 1). The preoperative evaluation of the patient being considered for pneumonectomy, and clinical issues relating to the outcome, sequelae, and complications following pneumonectomy will be reviewed here. A general discussion of preoperative evaluation prior to lung resection surgery is presented separately. (See "Preoperative evaluation for lung resection".)


Immediately following pneumonectomy, air fills the space previously occupied by the lung (ie, the postpneumonectomy space [PPS]). Unlike the situation with most other forms of thoracic surgery, a chest tube is not inserted following pneumonectomy, and the air is therefore not evacuated. Over time, a number of changes result in a decrease in the size of the PPS, including elevation of the hemidiaphragm, hyperinflation of the remaining lung, and shifting of the mediastinum towards the PPS. At the same time, there is progressive resorption of air in the PPS and replacement with fluid.

Chest radiographic findings immediately after surgery demonstrate the trachea to be midline and the PPS to be filled with air (image 1A-B). Within 24 hours the ipsilateral hemidiaphragm becomes slightly elevated, the mediastinum shifts slightly towards the PPS, and fluid starts accumulating in the PPS. As a general rule, fluid accumulates at a rate of one to two intercostal spaces per day in the immediate postoperative period. The median time to 70 percent opacification (fluid at the level of the main carina on an upright chest radiograph) is three days [4]. As pleural pressure increases, the rate of fluid accumulation decreases, and after two weeks, 80 to 90 percent of the PPS is filled with fluid.

By chest radiograph, complete opacification of the hemithorax after pneumonectomy takes an average of approximately four months, with a range from three weeks to seven months [5]. Unexpectedly rapid accumulation of fluid into the PPS in the immediate postoperative period should raise concerns for hemorrhage into the PPS, infection of the PPS, or the development of a chylothorax. While the chest radiograph typically demonstrates complete opacification of the hemithorax, chest CT scans demonstrate that only a small fraction of patients have obliteration of their PPS, with most patients having residual fluid and/or air [6]. The length of time following pneumonectomy does not correlate with complete obliteration of the space nor the amount of fluid remaining in the space.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Dec 19, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. James TW, Faber LP. Indications for pneumonectomy. Pneumonectomy for malignant disease. Chest Surg Clin N Am 1999; 9:291.
  2. Conlan AA, Kopec SE. Indications for pneumonectomy. Pneumonectomy for benign disease. Chest Surg Clin N Am 1999; 9:311.
  3. Kopec SE, Irwin RS, Umali-Torres CB, et al. The postpneumonectomy state. Chest 1998; 114:1158.
  4. Munden RF, O'Sullivan PJ, Liu P, Vaporciyan AA. Radiographic evaluation of the pleural fluid accumulation rate after pneumonectomy. Clin Imaging 2015; 39:247.
  6. Suarez J, Clagett T, Brown AL Jr. The postpneumonectomy space: factors influencing its obliteration. J Thorac Cardiovasc Surg 1969; 57:539.
  7. Smulders SA, Holverda S, Vonk-Noordegraaf A, et al. Cardiac function and position more than 5 years after pneumonectomy. Ann Thorac Surg 2007; 83:1986.
  8. Kopec SE, Conlan AA, Irwin RS. Perforation of the right ventricle: a complication of blind placement of a chest tube into the postpneumonectomy space. Chest 1998; 114:1213.
  9. Harpole DH, Liptay MJ, DeCamp MM Jr, et al. Prospective analysis of pneumonectomy: risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 1996; 61:977.
  10. Harpole DH Jr, DeCamp MM Jr, Daley J, et al. Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg 1999; 117:969.
  11. Watanabe S, Asamura H, Suzuki K, Tsuchiya R. Recent results of postoperative mortality for surgical resections in lung cancer. Ann Thorac Surg 2004; 78:999.
  12. Ramnath N, Demmy TL, Antun A, et al. Pneumonectomy for bronchogenic carcinoma: analysis of factors predicting survival. Ann Thorac Surg 2007; 83:1831.
  13. Ludwig C, Stoelben E, Olschewski M, Hasse J. Comparison of morbidity, 30-day mortality, and long-term survival after pneumonectomy and sleeve lobectomy for non-small cell lung carcinoma. Ann Thorac Surg 2005; 79:968.
  14. Miller DL, Deschamps C, Jenkins GD, et al. Completion pneumonectomy: factors affecting operative mortality and cardiopulmonary morbidity. Ann Thorac Surg 2002; 74:876.
  15. Sherwood JT, Mitchell JD, Pomerantz M. Completion pneumonectomy for chronic mycobacterial disease. J Thorac Cardiovasc Surg 2005; 129:1258.
  16. Kim DJ, Lee JG, Lee CY, et al. Long-term survival following pneumonectomy for non-small cell lung cancer: clinical implications for follow-up care. Chest 2007; 132:178.
  17. Harmon H, Fergus S, Cole FH. Pneumonectomy: review of 351 cases. Ann Surg 1976; 183:719.
  18. Wahi R, McMurtrey MJ, DeCaro LF, et al. Determinants of perioperative morbidity and mortality after pneumonectomy. Ann Thorac Surg 1989; 48:33.
  19. Terzi A, Lonardoni A, Falezza G, et al. Completion pneumonectomy for non-small cell lung cancer: experience with 59 cases. Eur J Cardiothorac Surg 2002; 22:30.
  20. Puri V, Tran A, Bell JM, et al. Completion pneumonectomy: outcomes for benign and malignant indications. Ann Thorac Surg 2013; 95:1885.
  21. Alfici R, Ashkenazi I, Kounavsky G, Kessel B. Total pulmonectomy in trauma: a still unresolved problem--our experience and review of the literature. Am Surg 2007; 73:381.
  22. Ferguson MK, Reeder LB, Mick R. Optimizing selection of patients for major lung resection. J Thorac Cardiovasc Surg 1995; 109:275.
  23. Bagan P, Berna P, De Dominicis F, et al. Nutritional status and postoperative outcome after pneumonectomy for lung cancer. Ann Thorac Surg 2013; 95:392.
  24. Dales RE, Dionne G, Leech JA, et al. Preoperative prediction of pulmonary complications following thoracic surgery. Chest 1993; 104:155.
  25. Leo F, Scanagatta P, Baglio P, et al. The risk of pneumonectomy over the age of 70. A case-control study. Eur J Cardiothorac Surg 2007; 31:780.
  26. Ginsberg RJ, Hill LD, Eagan RT, et al. Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 1983; 86:654.
  27. Silvestri GA, Handy J, Lackland D, et al. Specialists achieve better outcomes than generalists for lung cancer surgery. Chest 1998; 114:675.
  28. Krasna MJ. COUNTERPOINT: Pneumonectomy after chemoradiation: the risks of trimodality therapy. J Thorac Cardiovasc Surg 2009; 138:295.
  29. Gaissert HA, Keum DY, Wright CD, et al. POINT: Operative risk of pneumonectomy--influence of preoperative induction therapy. J Thorac Cardiovasc Surg 2009; 138:289.
  30. Thomas P, Michelet P, Barlesi F, et al. Impact of blood transfusions on outcome after pneumonectomy for thoracic malignancies. Eur Respir J 2007; 29:565.
  31. Deslauriers J, Ugalde P, Miro S, et al. Adjustments in cardiorespiratory function after pneumonectomy: results of the pneumonectomy project. J Thorac Cardiovasc Surg 2011; 141:7.
  32. Laros CD, Westermann CJ. Dilatation, compensatory growth, or both after pneumonectomy during childhood and adolescence. A thirty-year follow-up study. J Thorac Cardiovasc Surg 1987; 93:570.
  33. Fragkidis A, Dimitriou A, Dougenis D. Coronary artery bypass grafting and/or valvular surgery in patients with previous pneumonectomy. J Cardiothorac Surg 2012; 7:110.
  34. Fukui Y, Kohno T, Fujimori S, et al. Three-port thoracoscopic middle lobectomy in a patient after left pneumonectomy. Ann Thorac Surg 2015; 99:1422.
  35. Reed CE, Spinale FG, Crawford FA Jr. Effect of pulmonary resection on right ventricular function. Ann Thorac Surg 1992; 53:578.
  36. Okada M, Ota T, Okada M, et al. Right ventricular dysfunction after major pulmonary resection. J Thorac Cardiovasc Surg 1994; 108:503.
  37. Kowalewski J, Brocki M, Dryjański T, et al. Right ventricular morphology and function after pulmonary resection. Eur J Cardiothorac Surg 1999; 15:444.
  38. Bolliger CT, Wyser C, Roser H, et al. Lung scanning and exercise testing for the prediction of postoperative performance in lung resection candidates at increased risk for complications. Chest 1995; 108:341.
  39. Mossberg B, BJORK O, Holmgren A. Working capacity and cardiopulmonary function after extensive lung resections. Scand J Thorac Cardiovasc Surg 1976; 10:247.
  40. Bryant AS, Cerfolio RJ, Minnich DJ. Survival and quality of life at least 1 year after pneumonectomy. J Thorac Cardiovasc Surg 2012; 144:1139.
  41. Leo F, Scanagatta P, Vannucci F, et al. Impaired quality of life after pneumonectomy: who is at risk? J Thorac Cardiovasc Surg 2010; 139:49.
  42. Cerfolio RJ, Bryant AS, Thurber JS, et al. Intraoperative solumedrol helps prevent postpneumonectomy pulmonary edema. Ann Thorac Surg 2003; 76:1029.
  43. Jordan S, Mitchell JA, Quinlan GJ, et al. The pathogenesis of lung injury following pulmonary resection. Eur Respir J 2000; 15:790.
  44. Mehran RJ, Deslauriers J. Late complications. Postpneumonectomy syndrome. Chest Surg Clin N Am 1999; 9:655.
  45. Valji AM, Maziak DE, Shamji FM, Matzinger FR. Postpneumonectomy syndrome: recognition and management. Chest 1998; 114:1766.
  46. Sakiyalak P, Vigneswaran WT. Postpneumonectomy syndrome in single lung transplantation recipient following previous pneumonectomy. Ann Thorac Surg 2003; 75:1023.
  47. Régnard JF, Pouliquen E, Magdeleinat P, et al. [Postpneumonectomy syndrome in adults: description and therapeutic propositions apropos of 8 cases]. Rev Mal Respir 1999; 16:1113.
  48. Kelly RF, Hunter DW, Maddaus MA. Postpneumonectomy syndrome after left pneumonectomy. Ann Thorac Surg 2001; 71:701.
  49. Shen KR, Wain JC, Wright CD, et al. Postpneumonectomy syndrome: surgical management and long-term results. J Thorac Cardiovasc Surg 2008; 135:1210.
  50. Yüksel M, Yildizeli B, Evman S, Kodalli N. Postpneumonectomy esophageal compression: an unusual complication. Eur J Cardiothorac Surg 2005; 28:180.
  51. Partington SL, Graham A, Weeks SG. Pulmonary vein stenosis following left pneumonectomy: a variant contributor to postpneumonectomy syndrome. Chest 2010; 137:205.
  52. Merritt RE, Reznik SI, DaSilva MC, et al. Benign emptying of the postpneumonectomy space. Ann Thorac Surg 2011; 92:1076.
  53. Abbas Ael-S, Deschamps C. Postpneumonectomy empyema. Curr Opin Pulm Med 2002; 8:327.
  54. Schneiter D, Cassina P, Korom S, et al. Accelerated treatment for early and late postpneumonectomy empyema. Ann Thorac Surg 2001; 72:1668.
  55. Deschamps C, Allen MS, Miller DL, et al. Management of postpneumonectomy empyema and bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001; 13:13.
  56. Schneiter D, Grodzki T, Lardinois D, et al. Accelerated treatment of postpneumonectomy empyema: a binational long-term study. J Thorac Cardiovasc Surg 2008; 136:179.
  57. Gossot D, Stern JB, Galetta D, et al. Thoracoscopic management of postpneumonectomy empyema. Ann Thorac Surg 2004; 78:273.
  58. Hollaus PH, Lax F, Wurnig PN, et al. Videothoracoscopic debridement of the postpneumonectomy space in empyema. Eur J Cardiothorac Surg 1999; 16:283.
  59. Darling GE, Abdurahman A, Yi QL, et al. Risk of a right pneumonectomy: role of bronchopleural fistula. Ann Thorac Surg 2005; 79:433.
  60. 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.
  61. Panagopoulos ND, Apostolakis E, Koletsis E, et al. Low incidence of bronchopleural fistula after pneumonectomy for lung cancer. Interact Cardiovasc Thorac Surg 2009; 9:571.
  62. Roselli EE, Murthy SC, Rice TW, et al. Atrial fibrillation complicating lung cancer resection. J Thorac Cardiovasc Surg 2005; 130:438.
  63. Foroulis CN, Kotoulas C, Lachanas H, et al. Factors associated with cardiac rhythm disturbances in the early post-pneumonectomy period: a study on 259 pneumonectomies. Eur J Cardiothorac Surg 2003; 23:384.
  64. Sugarbaker DJ, Jaklitsch MT, Bueno R, et al. Prevention, early detection, and management of complications after 328 consecutive extrapleural pneumonectomies. J Thorac Cardiovasc Surg 2004; 128:138.
  65. Onaitis M, D'Amico T, Zhao Y, et al. Risk factors for atrial fibrillation after lung cancer surgery: analysis of the Society of Thoracic Surgeons general thoracic surgery database. Ann Thorac Surg 2010; 90:368.
  66. Tisdale JE, Wroblewski HA, Wall DS, et al. A randomized trial evaluating amiodarone for prevention of atrial fibrillation after pulmonary resection. Ann Thorac Surg 2009; 88:886.
  67. Lanza LA, Visbal AI, DeValeria PA, et al. Low-dose oral amiodarone prophylaxis reduces atrial fibrillation after pulmonary resection. Ann Thorac Surg 2003; 75:223.
  68. Amar D, Roistacher N, Burt ME, et al. Effects of diltiazem versus digoxin on dysrhythmias and cardiac function after pneumonectomy. Ann Thorac Surg 1997; 63:1374.
  69. Borgeat A, Biollaz J, Bayer-Berger M, et al. Prevention of arrhythmias by flecainide after noncardiac thoracic surgery. Ann Thorac Surg 1989; 48:232.
  70. Van Mieghem W, Tits G, Demuynck K, et al. Verapamil as prophylactic treatment for atrial fibrillation after lung operations. Ann Thorac Surg 1996; 61:1083.
  71. Ritchie AJ, Bowe P, Gibbons JR. Prophylactic digitalization for thoracotomy: a reassessment. Ann Thorac Surg 1990; 50:86.
  72. Riber LP, Larsen TB, Christensen TD. Postoperative atrial fibrillation prophylaxis after lung surgery: systematic review and meta-analysis. Ann Thorac Surg 2014; 98:1989.
  73. Ommen SR, Odell JA, Stanton MS. Atrial arrhythmias after cardiothoracic surgery. N Engl J Med 1997; 336:1429.
  74. Mason DP, Quader MA, Blackstone EH, et al. Thromboembolism after pneumonectomy for malignancy: an independent marker of poor outcome. J Thorac Cardiovasc Surg 2006; 131:711.
  75. Raja S, Idrees JJ, Blackstone EH, et al. Routine venous thromboembolism screening after pneumonectomy: The more you look, the more you see. J Thorac Cardiovasc Surg 2016; 152:524.
  76. Kameyama K, Huang CL, Liu D, et al. Pulmonary embolism after lung resection: diagnosis and treatment. Ann Thorac Surg 2003; 76:599.
  77. Self RJ, Vaughan RS. Acute cardiac herniation after radical pleuropneumonectomy. Anaesthesia 1999; 54:564.
  78. Shimizu J, Ishida Y, Hirano Y, et al. Cardiac herniation following intrapericardial pneumonectomy with partial pericardiectomy for advanced lung cancer. Ann Thorac Cardiovasc Surg 2003; 9:68.
  79. Veronesi G, Spaggiari L, Solli PG, Pastorino U. Cardiac dislocation after extended pneumonectomy with pericardioplasty. Eur J Cardiothorac Surg 2001; 19:89.
  80. Foroulis C, Kotoulas C, Konstantinou M, Lioulias A. The use of pedicled pleural flaps for the repair of pericardial defects, resulting after intrapericardial pneumonectomy. Eur J Cardiothorac Surg 2002; 21:92.
  81. Blum MG, Sundaresan RS. Giant hiatal hernia with gastric volvulus complicating pneumonectomy. Ann Thorac Surg 2006; 81:1491.
  82. Ishikawa S, Griesdale DE, Lohser J. Acute kidney injury after lung resection surgery: incidence and perioperative risk factors. Anesth Analg 2012; 114:1256.