Neurogenic pulmonary edema masquerading as diffuse alveolar hemorrhage

Size matching between a donor and recipient is critical in lung transplantation. An oversized lung may lead to space compatibility issues and an undersized lung may lead to a more severe reperfusion injury syndrome. In general, the predicted total lung capacity (TLC), which is calculated using standard equations based on the height and sex of the donor and recipient, are used for assessing the volume mismatch. However, there is a discrepancy between the actual and predicted TLC, which varies according to the underlying lung physiology, such as idiopathic pulmonary fibrosis or chronic obstructive lung disease. If a significant size mismatch is identified, a planned non-anatomic lung volume reduction or lobar lung transplants may be required. Despite the volume reduction procedure, postoperative atelectasis occurred and led to delayed ECMOand ventilator-weaning, which is a potential risk factor in the early postoperative period. Generally, to prevent or resolve atelectasis, positive-pressure ventilation and performing the recruitment manoeuvre is the first-line therapy in the ICU. Prone position ventilation can be adopted in the refractory case to conventional ventilator management including recruitment manoeuvre. However, thoracic surgery has mostly been regarded as a relative contra-indication for using the prone position immediate postoperative period without significant morbidity. Considering this recommendation, prone position ventilation is not likely to be adopted in the immediate postoperative period after traditional anterolateral thoracosternotomy. Here, we present a case of post-operative atelectasis which was safely treated by prone positioning immediately after lung transplantation with bilateral sequential anterior thoracotomy.