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This is a case report formatted as a clinical handover discussion between a junior ward paediatrician (SB) and senior paediatric intensive care consultant (AD) and cardiology consultant (GM).
SB: I have been handed over a 3-year-old patient from the paediatric intensive care unit (PICU). She has a complex medical history and spent the first year of her life in PICU. She had a repair of a hypoplastic-aortic-arch and a tracheo-oesophageal fistula as a neonate but remained ventilator dependent for months with left main bronchus (LMB) compression. Separation from the ventilator was eventually achieved, after a failed aortopexy, with a 20×6 mm Palmaz metallic stent inserted into the LMB. This permitted discharge home for 2 years but she gradually outgrew the neonatal stent, which had become embedded within the LMB.
She represented with recurrent chest infections and left lung collapse, thus necessitating removal and replacement of the LMB stent. The patient also had aortic valve stenosis and required corrective open heart surgery. As she was undergoing bypass, it was decided to remove the embedded bronchial stent during the valve repair.
During bypass surgery, a small bronchial incision was made through which the embedded stent was removed. Due to heparinisation, the procedure was complicated by significant mucosal bleeding into the LMB, which filled the left lung with blood. Postprocedure, the left lung remained opacified on X-ray (figure 1A). The PICU team were unable to open the lung despite physiotherapy, saline lavage, bronchoscopy and high-pressure dual lung ventilation. However, she has been transferred to the ward self-ventilating in air and her last chest X-ray showed reinflation of the left lung, how was this achieved given that all conventional methods failed?
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