perioperative management challenges for post-tuberculous stage-iii empyema with massive pneumothorax mimicking vanishing lung syndrome: a case report

Surgical resection is frequently the intervention required for post-tuberculous empyema or other sequels. however, pneumonectomy may not be feasible in some situations, and video-assisted thoracoscopic surgery (vats) plays a role in such a scenario. whether a patient undergoes open resection of vats, isolation of infected lung is integral to one-lung ventilation and better access to the surgical field, and a double-lumen tube (dlt) remains the preferred choice. difficulties in dlt placement after pneumonectomy are reported; however, failure to isolate a lung by appropriately placed dlt is scarce or absent. a 28-year cachectic gentleman with poor preoperative lung function was suffering from endobronchial tuberculosis. he also had one episode of tuberculosis twelve-year back. at presentation, he had a massive pneumothorax and stage-iii empyema as a sequel, including a rare finding of plastered mediastinum mimicking vanishing lung syndrome. he underwent uniportal-vats under general anesthesia using one-lung ventilation. complete lung destruction from active tuberculosis and its sequel leading to the plastered mediastinum and deformed airway pose a significant lung isolation challenge. u vats can be considered for therapeutic purpose where standard thoracotomy and pneumonectomy is contra-indicated. however, lung isolation in such patients is tricky and poses a risk. the present case highlights the challenges faced with lung isolation using a dlt and discusses the probable remedy to these problems.