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A pneumonectomy removes a whole lung, usually for cancer that cannot be treated by taking less. The space left behind slowly fills with fluid over weeks and the heart shifts slightly towards it. Because there is no lung on that side any more, treatments aimed at re-inflating it make no sense — and some of them can be harmful.
When a whole lung comes out
Pneumonectomy is performed when a lesser resection cannot clear the disease — typically a central tumour involving the main bronchus or pulmonary artery, or extensive disease crossing a fissure. Rates have fallen as sleeve resection and parenchyma-sparing techniques have improved, and that fall is deliberate: pneumonectomy carries higher mortality and a materially different complication profile than lobectomy.1,2
Extrapleural pneumonectomy for mesothelioma — removing lung, pleura, pericardium and diaphragm — is now rarely performed. Randomised evidence in MARS 2 found no survival benefit from extended pleurectomy decortication over chemotherapy alone, and the radical surgical era in mesothelioma has effectively closed.3 See Mesothelioma.
Operability assessment is more demanding than for lobectomy because more function is lost: predicted post-operative values are calculated against the whole lung, and a peak oxygen uptake above 20 mL/kg/min is generally required.1,2 See Lung Resection & Lobectomy and Cardiopulmonary Exercise Testing.
The post-pneumonectomy space
The hemithorax is left empty. Over the following weeks it fills progressively with serous fluid, the mediastinum shifts towards the operated side, the diaphragm rises and the remaining lung hyperinflates slightly to compensate. This is the expected course, not a complication.
Two consequences follow immediately:
- There is nothing to re-expand. Any technique whose rationale is re-inflating the operated side is meaningless. A dull, silent hemithorax on that side is the expected finding.
- Drain management is different. Where a drain is used it is typically clamped and released intermittently rather than placed on suction, to control the rate of mediastinal shift. Never alter a pneumonectomy drain's clamp status — that is a surgical decision.
A rapid change in mediastinal position is dangerous in either direction. Sudden breathlessness, cardiovascular instability or a change in tracheal position needs urgent surgical review.
What changes in physiotherapy practice
Practice after pneumonectomy varies between surgical units more than for almost any other thoracic operation, and much of it rests on physiological reasoning rather than trial evidence. The points below are the common positions — the operating team's instruction governs in every case.
Positive pressure and the bronchial stump
The main bronchial stump is a fresh suture line under tension, and it is the origin of the most feared late complication, bronchopleural fistula. Sustained positive pressure — non-invasive ventilation, intermittent positive pressure breathing, high-pressure positive expiratory pressure devices — should not be used without explicit surgical agreement. Low-pressure techniques, huffing and supported coughing are generally acceptable.
Fluid balance
Post-pneumonectomy pulmonary oedema is an uncommon but highly lethal complication affecting the remaining lung, and fluid is restricted deliberately as a result.4 Two practical implications: do not encourage large-volume oral intake without checking, and treat new breathlessness with hypoxaemia and fine crackles in the remaining lung as a medical emergency rather than a clearance problem.
Positioning
Many units limit prolonged lying with the remaining lung dependent, on the grounds that it compromises ventilation and perfusion of the only functioning lung and may influence mediastinal position. Others are less restrictive. This is a protocol question, not a principle to apply from first principles, and it should be confirmed and documented at the first contact.
Exercise and mobilisation
Early mobilisation remains correct and is part of enhanced recovery practice.5 Expect a lower ceiling than after lobectomy and progress by symptoms and oxygen saturation rather than by a protocol timetable.
Complications to recognise
| Complication | Presentation and response |
|---|---|
| Atrial fibrillation | Common after pneumonectomy, and less well tolerated because reserve is reduced. Use perceived exertion rather than heart rate to prescribe. |
| Post-pneumonectomy pulmonary oedema | Breathlessness, hypoxaemia and infiltrates in the remaining lung within the first days. High mortality. Escalate immediately. |
| Bronchopleural fistula | Fever, a productive cough of thin serous fluid, and a falling fluid level on imaging. Position the patient operated side down to protect the remaining lung from spillage and escalate urgently. |
| Empyema of the space | Systemic sepsis with a filled hemithorax. Surgical problem. |
| Cardiac herniation | Rare, catastrophic, usually early and after intrapericardial resection. Sudden cardiovascular collapse with position change. |
| Right heart strain | The entire cardiac output now passes through one lung. Exercise-limiting breathlessness with signs of right heart failure warrants review. |
| Post-pneumonectomy syndrome | Late. Excessive mediastinal rotation causing airway compression, breathlessness and stridor, months to years after surgery. |
Longer-term function
Loss of a lung does not halve exercise capacity, but it does reduce it durably. Cardiorespiratory adjustment after pneumonectomy has been studied prospectively: patients settle at a reduced but functional capacity, with the limitation shifting towards ventilatory and pulmonary vascular constraints during exertion.6 Recovery is slower than patients expect and continues over many months.
Rehabilitation is worthwhile and should be prescribed rather than assumed impossible. Progress by symptom response and saturation, expect desaturation on exertion in some patients, and set functional rather than normative goals.
Role of the physiotherapist
Establish that the operation was a pneumonectomy and not a lobectomy — this is the single most important fact, and it is easily missed in a handover. Confirm the unit's position on positive pressure, positioning and fluid before treating. Abandon any re-expansion rationale for the operated side. Mobilise early, prescribe by symptoms, and know which sudden deteriorations are surgical emergencies rather than treatable respiratory problems.
Evidence summary
Framing. Pneumonectomy is uncommon and becoming more so, which is precisely why it is a risk: many clinicians will meet it rarely and will default to lobectomy habits.1,2 The physiological situation is genuinely different — a fixed empty hemithorax, a single lung carrying the entire cardiac output, a vulnerable bronchial stump and deliberate fluid restriction — and several standard interventions are contraindicated or meaningless.
Evidence — selection and outcomeERS/ESTS and ACCP frameworks set higher functional thresholds for pneumonectomy than for lesser resections, with peak oxygen uptake the arbiter in the intermediate zone.1,2 Prospective study of cardiorespiratory adjustment after pneumonectomy describes the durable but sub-maximal functional endpoint patients reach.6 Post-pneumonectomy pulmonary oedema remains an uncommon, poorly predicted and highly lethal complication driving conservative fluid management.4 MARS 2 closed the argument for radical surgery in mesothelioma.3
Physiotherapy implicationsMost of what differs here is not evidence-based in the trial sense; it is physiological reasoning codified into unit protocol, and the correct professional behaviour is to establish and follow the local position rather than to generalise. The non-negotiables are: no unsanctioned positive pressure, no alteration of drain clamp status, no re-expansion rationale for the operated hemithorax, and immediate escalation of new breathlessness with hypoxaemia.
Evidence gapsThere is no trial evidence guiding positioning, airway clearance technique or the safety of specific pressures after pneumonectomy, and practice variation between units is wide and undocumented. Rehabilitation prescription is extrapolated from lobectomy cohorts. The long-term functional trajectory is described in small prospective series rather than in adequately powered studies.
References & evidence base
- Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients. Eur Respir J 2009;34(1):17–41.
- Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidence-based clinical practice guidelines. Chest 2013;143(5 Suppl):e166S–e190S.
- Lim E, Waller D, Lau K, et al. Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for mesothelioma (MARS 2): a phase 3 randomised controlled trial. Lancet Respir Med 2024;12(6):457–466.
- Slinger PD. Post-pneumonectomy pulmonary edema: good news, bad news. Anesthesiology 2006;105(1):2–5.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: ERAS Society and European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
- 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(1):7–15.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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