Staged postoperative veno-venous ECMO weaning as a bridge to spontaneous breathing after uniportal thoracoscopic lung volume reduction for giant bullous emphysema: a case report

Abstract Background Patients with advanced chronic obstructive pulmonary disease and giant bullae often have severely limited pulmonary reserve, and many cannot tolerate the single-lung ventilation that conventional thoracic surgery requires. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) can support gas exchange during surgery; when continued afterwards, it may also allow the lung to rest while spontaneous breathing recovers. Maintaining extracorporeal support while avoiding or withdrawing invasive mechanical ventilation is an established concept in awake-ECMO and lung-transplant bridging practice, but it has rarely been described after uniportal thoracoscopic surgery for giant bullae. Case presentation A 79-year-old man had a 20-year history of chronic obstructive pulmonary disease on triple inhaled therapy and long-term home oxygen, bullae in both lungs, chronic type II respiratory failure, and three prior episodes of right pneumothorax over eight months, followed by a current recurrence with a persistent air leak. His limited reserve and the risk of rupturing the large left-sided bulla during ventilation of that lung made single-lung ventilation unsafe. After multidisciplinary assessment, he underwent uniportal video-assisted thoracoscopic lung volume reduction of a giant right lower-lobe bulla under VV-ECMO support. The giant bulla and adjacent emphysematous lung were resected with buttressed staple lines, and pleurodesis was performed. Rather than decannulating in theatre, extracorporeal support was deliberately continued to allow the lung to rest. The trachea was extubated on the first postoperative day with conversion to high-flow nasal oxygen, protected breathing training was undertaken while support continued, and the patient was decannulated on the fourth postoperative day after a 5-h trial with the sweep gas switched off. The chest tube was removed on day 10. At six months he had no recurrent pneumothorax, used intermittent home oxygen, and could walk 500 to 1000 m slowly. Conclusions Uniportal thoracoscopic lung volume reduction under VV-ECMO is feasible in selected elderly, high-risk patients with advanced chronic obstructive pulmonary disease and giant bullae. Separating ventilator weaning from extracorporeal weaning in time may allow spontaneous breathing to recover while airway pressure over a fresh staple line is kept low. Whether this approach generalises beyond a single patient remains to be established.