Anesthetic management of bronchopleural fistula repair with severe pneumonia in a 74-year-old man using one-lung ventilation combined with high-flow veno-venous extracorporeal membrane oxygenation without continuous systemic heparinization: a case report

Background: Bronchopleural fistula (BPF) is a serious complication following lung resection, often leading to respiratory failure. In one study of 6,239 patients, 43 (0.65%) developed early bronchopleural fistula, and cases complicated by contralateral pneumonia have rarely been reported.

Case Description: We present the case of a 74-year-old man with chronic obstructive pulmonary disease, atrial fibrillation, hypertension, and pneumonia who developed bronchopleural fistula after thoracoscopic left upper lobectomy. The patient was scheduled to undergo BPF repair, in which includes an intercostal muscle flap was sutured in place. Due to extensive pneumonia and poor contralateral lung function, one-lung ventilation along with high-flow veno-venous extracorporeal membrane oxygenation (V-V ECMO) was used intraoperatively to maintain oxygenation. ECMO was managed without continuous systemic heparinization to reduce the risk of bleeding and to allow for postoperative epidural anesthesia. The patient was extubated postoperatively under spontaneous breathing with adequate analgesia, avoiding tachypnea due to pain. Although the patient’s initial postoperative course was uneventful, he experienced sudden massive hemoptysis on postoperative day 6 and died.

Conclusions: Although this approach may be technically feasible in carefully selected cases, it should be considered a high-risk strategy for perioperative management during BPF repair in patients with severe lung injury. Given the limited evidence currently available, further data are needed to establish its safety and efficacy.