Postoperative pulmonary rehabilitation care for a case of acute perfluorocarbon poisoning undergoing lung transplantation: a case report

Introduction

Perfluoro(4-methyl-2-pentene), with the molecular formula C₆F₁₂, is an organic fluorine compound that is a colorless, transparent liquid at room temperature and pressure. When exposed to high temperatures, it pyrolyzes into highly toxic gases. Inhalation of excessive C₆F₁₂ pyrolysis gas can lead to severe non-cardiogenic pulmonary edema, skin and lung burns, potentially presenting as respiratory distress, severe acute respiratory distress syndrome (ARDS), and respiratory failure (1,2). Lung transplantation is an effective treatment for severe lung injury caused by acute perfluorocarbon poisoning. Pulmonary rehabilitation is a crucial component of postoperative recovery for lung transplant patients, directly impacting their perioperative and home-based recovery quality of life (3). It encompasses various aspects, including respiratory function training, exercise training, nutritional support, and psychological care. In December 2024, a patient with severe lung injury caused by C₆F₁₂ poisoning was admitted to our hospital and successfully underwent bilateral lung transplantation. After careful multidisciplinary treatment and rehabilitation nursing, the patient was discharged on postoperative day 53. The relevant experience of pulmonary rehabilitation nursing is reported as follows. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0004/rc).

Case presentation

A 26-year-old male presented with chest tightness, shortness of breath, and dyspnea, accompanied by epigastric pain, nausea, vomiting, and hallucinations, but no loss of consciousness, after working for approximately 40 minutes in a unit’s high-voltage distribution room (an enclosed space) on the evening of November 13, 2024. On November 14, 2024, he sought medical attention at a local hospital. External computed tomography (CT) showed diffuse bilateral lung changes, considered lung injury caused by exposure to toxic and harmful substances (later identified as C₆F₁₂). He received continuous renal replacement therapy (CRRT), mechanical ventilatory support, and steroid pulse therapy, with poor response, and his dyspnea worsened. On November 29, he was transferred to a municipal tertiary Grade A hospital, diagnosed with “Acute Respiratory Distress Syndrome, Type II Respiratory Failure, Pneumonia after Inhalation of Toxic Gas”. He was managed with venous-venous extracorporeal membrane oxygenation (VV-ECMO), endotracheal intubation, mechanical ventilatory support, and anti-fibrotic therapy. A CT on December 6 revealed diffuse bilateral lung changes and bilateral hydropneumothorax. On December 12, arterial blood gas showed partial pressure of oxygen in arterial blood (PaO₂): 42.4 mmHg, partial pressure of carbon dioxide in arterial blood (PaCO₂): 42.9 mmHg, and a partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO₂/FiO₂) ratio of 42.4 mmHg. He was transferred to our hospital’s intensive care unit (ICU) for lung transplantation evaluation.

After admission, invasive ventilation and VV-ECMO support were continued. A tracheostomy was performed on December 13. Following a comprehensive preoperative evaluation and multidisciplinary team (MDT) discussion, the patient underwent allogeneic bilateral lung transplantation under general anesthesia with Venous-Arterial-Venous ECMO (VAV-ECMO) support on December 24, 2024. Postoperatively, he returned to the ICU, continuing with orotracheal intubation connected to a ventilator and VV-ECMO support. On December 28th, ECMO was discontinued while closely monitoring respiratory function and implementing a protective ventilation strategy to promote pulmonary function recovery. Postoperative fiberoptic bronchoscopy was performed to assess the lungs, and bilateral bronchoalveolar lavage fluid was collected for culture, guiding antibiotic therapy optimization. A nasoenteral tube was placed for enteral nutrition, alongside acid suppression therapy. On January 13, 2025, a lower limb ultrasound indicated bilateral calf muscular venous thrombosis, and anticoagulant therapy was initiated. Successful weaning from the ventilator was achieved on January 31, followed by sequential tracheostomy with high-flow humidified oxygen therapy. Rehabilitation physicians guided respiratory function training, cough training, and assisted with limb functional exercises. The patient’s condition stabilized, and he was transferred to the general ward on February 7. The tracheostomy metal cannula was removed on February 8, and he received oxygen via bilateral nasal cannula at 3 L/min, maintaining oxygen saturation above 99%. Through comprehensive monitoring by the MDT, lung-protective ventilation therapy, sequential oxygen therapy, personalized quantified rehabilitation training, precision nutritional support, restrictive fluid management, and supportive psychological care, the patient was discharged on February 14.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Multidisciplinary collaboration: establishing a dedicated pulmonary rehabilitation team

Given the critical condition and prolonged course of the patients, who exhibited issues such as muscle atrophy, malnutrition, and psychological distress postoperatively, a multidisciplinary pulmonary rehabilitation team was established to facilitate rapid recovery. The team comprised 6 nurses, 4 physicians, 1 rehabilitation therapist, 1 respiratory therapist, 1 nutritionist, and 1 psychotherapist, providing continuous pulmonary rehabilitation management in both the ICU and general ward to ensure continuity and effectiveness post-lung transplantation. The nursing team consisted of 6 experienced lung transplant specialist nurses, including 4 ICU nurses and 2 ward nurses, all holding senior nurse licensure. The lung transplant specialist nurses played a leading role within the rehabilitation team, acting as decision-makers, implementers, and coordinators (3). Their responsibilities included assessing existing risks, deciding on pulmonary rehabilitation nursing plans, implementing these plans, providing feedback on rehabilitation outcomes, and refining the nursing strategies. The lung transplant physicians assisted in formulating the rehabilitation plans, assessed their rationality and safety, and monitored postoperative lung function recovery. The rehabilitation therapist developed and implemented the pulmonary rehabilitation training plan, providing training and therapy. The respiratory therapist was responsible for assessing respiratory parameters, guiding respiratory training, and assisting with breathing strategies. The nutritionist assessed nutritional status and devised precise, individualized nutritional support plans. The psychotherapist evaluated psychological status and provided personalized psychological counseling. Research by Zeng et al. (4) also indicates that multidisciplinary team pulmonary rehabilitation nursing can effectively promote rapid recovery and shorten postoperative hospital stays for lung transplant recipients.

Mechanical ventilation and sequential oxygen therapy

Patients with fluorosis may initially exhibit elevated inflammatory markers, hypoxemia, and inflammatory patches on chest CT, followed by significant respiratory tract irritation symptoms, potentially progressing to severe pneumonia requiring ECMO-supported lung transplantation (5). ECMO is a crucial means of respiratory support for lung transplant patients during the perioperative period, with the mode selected flexibly based on cardiac function (6). The patient underwent tracheostomy and was connected to mechanical ventilation during the perioperative period (i.e., from December 13 to January 31). This established a stable artificial airway, provided reliable long-term respiratory support, facilitated airway management such as sputum suction and secretion clearance, reduced the risk of pulmonary infection, and improved patient comfort, communication ability, and mobility, thereby promoting rehabilitation and nursing care (7). During the postoperative period when the patient required mechanical ventilation (i.e., from December 24 to January 31), a modern lung-protective ventilation strategy was employed, including reduced tidal volume, appropriate positive end-expiratory pressure (PEEP), and repeated recruitment maneuvers (8). In this case, the ventilator was set to pressure support ventilation (PSV) mode, controlling positive pressure ventilation parameters to avoid lung injury. Specific settings included: pressure support (PS) 14 cmH₂O, PEEP 4–6 cmH₂O, FiO₂ 45–60%, respiratory rate (RR) 15 breaths/minute. Airway pressure and tidal volume were monitored to assess lung compliance, pulmonary edema, and sputum status. When airway pressure increased and tidal volume decreased, the dedicated pulmonary rehabilitation team dynamically monitored arterial blood gas results and implemented corresponding interventions such as suctioning, diuresis, and improving drainage, promptly followed by repeat bedside chest X-rays. Under lung-protective strategy treatment, the patients’ conditions gradually improved, allowing for a gradual reduction in ventilator oxygen concentration. Dynamic blood gas analysis showed: PaO₂/FiO₂ ratio 350 mmHg, PaCO₂ 45 mmHg. The ventilator displayed a tidal volume of 500 mL, indicating good ventilation capacity. Postoperative bronchoscopy revealed no significant pulmonary edema (watery secretions from the transplanted lung), and chest radiography showed no significant pulmonary exudation. The patient was extubated on January 31st after demonstrating clear consciousness, strong respiratory effort, and normal body temperature.

High-flow humidified oxygen therapy is a recommended method for sequential oxygen therapy after lung transplantation, offering advantages such as precise oxygen delivery, stable warming and humidification, improved ventilation function, high comfort, and reduced risk of complications (9). For this case, high-flow humidified oxygen therapy via tracheostomy was used as a transitional treatment during intermittent weaning periods. Settings included a flow rate of 40 L/min and FiO₂ 45%. Patient was encouraged to perform weaning exercises, gradually increasing the duration and frequency of weaning periods daily. Mechanical ventilation was discontinued on January 31st, after which high-flow oxygen therapy was continued to promote lung recruitment. The PaO₂/FiO₂ ratio was maintained above 300 mmHg for 3 consecutive days. During this period, the oxygen flow rate and concentration were gradually reduced. On February 8th, the patient was switched to nasal cannula oxygen therapy, with the flow rate gradually reduced from 5 to 1 L/min. The resting oxygen saturation was 100%, and by the time of discharge on February 14th, the patient had completely weaned off supplemental oxygen.

Personalized rehabilitation training

Respiratory function rehabilitation training

During the ECMO plus mechanical ventilation phase (i.e., from December 13 to December 28), the ECMO flow was gradually reduced to 2.5 L/min while maintaining oxygen saturation above 95% (10). During the mechanical ventilation-only phase (i.e., from December 29 to January 31), spontaneous breathing trials were conducted based on vital signs, each lasting 30–90 minutes. In the sequential assisted ventilation phase (i.e., from February 1 to February 14), the patient was guided to initiate active respiratory rehabilitation training, primarily including deep breathing, abdominal breathing, pursed-lip breathing, cough training, and the use of a respiratory training device to enhance inspiratory muscle strength. To address the physiological limitations and respiratory muscle dysfunction induced by denervation of the transplanted lung following lung transplantation, this protocol integrates deep breathing, abdominal breathing, and pursed-lip breathing exercises. These techniques are designed to promote alveolar recruitment, optimize respiratory coordination, and reduce airway collapse, respectively. Their synergistic effects form a key non-pharmacological intervention strategy for preventing complications and enhancing respiratory function recovery. The implementation plan for this patient’s respiratory function rehabilitation training is shown in Table 1. Respiratory exercises followed the principles of appropriate load and gradual progression. Concurrently with breathing training, airway clearance techniques were used to enhance airway management, including nebulization, suction as needed, percussion and postural drainage for expectoration, and fiberoptic bronchoscopy as needed (3).

Activity rehabilitation training

Pulmonary rehabilitation refers to comprehensive and personalized interventions based on a thorough assessment of the patient, including but not limited to exercise training, education, and behavior modification. These interventions are designed to improve the patient’s physical and psychological status and promote long-term adherence to health-promoting behaviors (11). The key components of pulmonary rehabilitation include endurance and resistance exercise training. The perioperative activity rehabilitation training intervention protocol for this lung transplant patient is as follows: Initiate passive mobilization and rehabilitation exercises during the ECMO + mechanical ventilation phase. On postoperative day 1, focus on passive joint mobilization of the limbs, such as ankle pumping and wrist/shoulder movements, 3 times daily for 10 minutes per session. Bedside sitting training commenced on postoperative day 2. The head of the bed was elevated to 60°–90°, and the patient sat upright against the bed, performed 3 times daily for 20 minutes each session. Passive bed cycling was conducted 3 times daily for 20 minutes each session. Concurrently, anti-thrombotic pump compression therapy was administered 3 times daily for 30 minutes each session.

During the later stages of the Mechanical Ventilation phase and the Sequential Assisted Ventilation phase, active exercise was emphasized, following a stepwise rehabilitation sequence of “Lying → Sitting → Standing → Walking”. This included limb training, such as extension exercises and resistance training for the upper limbs; straight leg raises and active bed cycling for the lower limbs. The frequency and duration increased from initially 2 times/day for 10 minutes/session to 5 times/day for 20 minutes/session by discharge. Bedside sitting training progressed from leaning against the bed to assisted sitting to independent sitting, incorporating daily sitting balance training, 3 times/day for 20 minutes/session. Standing training was conducted 3 times/day for 20 minutes/session. Walking training was performed with a walker, 2 times/day for 20 minutes/session. After 2 days of walking training, patient could walk without the walker for 30 minutes/session. At discharge, manual muscle testing of the upper limbs was grade 5, the 6-minute walk test distance reached 550 m, and he could perform sandbag-loaded walking exercises and climb 2 flights of stairs.

Swallowing and speech rehabilitation training

Due to tracheostomy, the patient experienced mild swallowing dysfunction, increasing the risk of aspiration, pulmonary infection, and even asphyxiation. The pulmonary rehabilitation team proactively administered metoclopramide/ondansetron to prevent vomiting. Swallowing function gradually recovered through orofacial organ training (including cheek puffing, chewing, mouth opening, lip pursing), cold stimulation training (using cold cotton swabs to stimulate the tongue base, soft palate, and posterior pharyngeal wall), and feeding training (12). A diet was initiated after assessing the Water Swallow Test as Grade I.

Communication barriers due to tracheostomy led to anxiety, helplessness, impaired self-identity, and reduced ability to participate interactively in rehabilitation (13). The pulmonary rehabilitation team provided patient with speech valves matching the tracheostomy cannula size for speech training. During valve use, patient was encouraged to vocalize and communicate, while closely monitoring vital signs, complexion, and complaints of chest tightness or discomfort. Using the speech valve effectively shortened the tracheostomy decannulation time, improved cough ability and respiratory function, and enhanced patient and family confidence in recovery.

Restrictive fluid management

The main aspects of post-lung transplant fluid management involve intake/output management and parameter monitoring. Postoperative fluid resuscitation should aim for a negative balance while maintaining stable circulatory function, to reduce fluid overload (14). Current reports on lung transplant volume management predominantly focus on restrictive fluid management and goal-directed fluid therapy (15). In this case, inhaled organic fluoride gas increased pulmonary capillary permeability, leading to fluid extravasation and acute pulmonary edema (16). Additionally, the transplanted lungs are edematous in the early postoperative period. Therefore, a restrictive fluid management strategy was adopted, requiring a daily negative fluid balance of 400–800 ml for the first 5 postoperative days, transitioning to fluid balance from days 6–8. Infusion speed was controlled using syringe pumps at 0.5–1.0 mL/(kg·h). The responsible nurse recorded intake and output hourly, precise to 0.1 mL. To maintain hemodynamic stability and tissue perfusion, multiple monitoring modalities (including pulmonary imaging, PaO₂/FiO₂ ratio, bronchoscopic findings, CVP, arterial blood pressure, urine output, and blood pressure) guided volume management.

Precision nutritional support

After assessment of swallowing function and gastric motility by nurses, trophic enteral nutrition support was initiated within 24 hours, using a post-pyloric feeding formula (Nutrison Fibre). Adhering to the principle of starting slow and low, then gradually increasing, feeding began at a low rate (15 mL/h) and was slowly increased to 65 mL/h based on gastrointestinal tolerance, with a maximum daily dose not exceeding 2,092 KJ (17). The multidisciplinary team assessed every 6 hours for vomiting, abdominal distension, diarrhea, gastric residual, aspiration, and gastrointestinal bleeding. The nutritional support dose was appropriately increased based on patient tolerance. Upon entering the sequential ventilation phase, and after team assessment of swallowing function, oral intake was initiated, following a progression from liquids to semi-solids to a regular diet.

Supportive psychological care

Fear of lung rejection, anxiety, and lack of confidence are barriers to rehabilitation activities (18). Thie lung transplant patient was young adult who suffered sudden, severe toxic lung injury due to occupational exposure, leading to significant psychological burden regarding future survival, work, life, and marriage. The psychotherapist employed cognitive-behavioral therapy and acceptance and commitment therapy for daily psychological treatment, helping patients adjust irrational cognitions and encouraging them to establish correct values. Guided by the psychologist, the team fully utilized a family-centered social support system, allowing patient visits whenever the condition permitted. When visits were not possible, daily phone calls or video calls connected patient with family and friends, maintaining his connection to the outside world. Music therapy was used to reduce stress hormone levels, alter emotional states, and guide the shift from anxiety and sadness towards calmness and pleasure. Under positive nursing care, patient confidence increased, leading to high cooperation with medical staff.

Continuity of care and follow-up management

Guidance from a multidisciplinary team and long-term, regular follow-up are essential for the postoperative rehabilitation of lung transplant patients (19). The lung transplant physicians and ward nurses within the pulmonary rehabilitation team conducted follow-up management, providing detailed instructions and standardized management regarding follow-up frequency, content, and strategies for handling special situations. Follow-ups were scheduled weekly for the first 3 months postoperatively, then monthly. Comprehensive reviews were conducted at 6 months and 12 months postoperatively, transitioning to every 2–3 months from the second year onward. Follow-up education was provided through both online and offline methods. Follow-up content included assessing immunosuppressant blood levels, complete blood count, blood biochemistry, pulmonary function tests, chest CT, exercise capacity, nutritional status, and psychological state, alongside medication guidance and health education.

Conclusions

Patients with severe acute perfluorocarbon poisoning are critically ill, suffering from significant lung injury and systemic dysfunction, making pulmonary rehabilitation after lung transplantation paramount. The pulmonary rehabilitation team must effectively manage mechanical ventilation and sequential oxygen therapy, rehabilitation training, fluid management, nutritional support, psychological care, and follow-up, all of which effectively promoted the postoperative recovery of these lung transplant recipients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0004/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0004/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0004/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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