What are the appropriate next steps for a patient experiencing a bubbling sensation in the remaining lung, productive cough with greenish sputum, and severe dyspnea two weeks post-bilobectomy?

Immediate Urgent Evaluation for Post-Bilobectomy Complications

This patient requires immediate hospital evaluation for life-threatening post-operative complications, specifically pneumonia with possible empyema, bronchopleural fistula, or pulmonary vein thrombosis—all of which can be fatal if not promptly diagnosed and treated.

Critical Red Flags Present

This clinical presentation two weeks post-bilobectomy demonstrates three alarming features that demand urgent action:

• Bubbling sensation in the remaining lung suggests air movement through abnormal pathways, potentially indicating a bronchopleural fistula or air leak 1
• Greenish sputum indicates bacterial infection, likely post-operative pneumonia or empyema
• Extreme breathlessness signals severe respiratory compromise that can rapidly deteriorate 2

Most Likely Diagnoses to Rule Out Immediately

1. Post-operative Pneumonia with Empyema

• Greenish purulent sputum is pathognomonic for bacterial infection requiring immediate antibiotic therapy
• Post-bilobectomy patients have compromised respiratory reserve and cannot tolerate prolonged infection 2
• The bubbling sensation may represent infected pleural fluid or air-fluid levels

2. Bronchopleural Fistula

• Abnormal communication between bronchus and pleural space can develop after lung resection
• Presents with bubbling sensations, productive cough, and progressive dyspnea
• Can lead to empyema and respiratory failure if untreated 3

3. Pulmonary Vein Thrombosis

• Rare but life-threatening complication specifically after bilobectomy 1
• Can cause severe dyspnea and respiratory compromise
• Requires anticoagulation to prevent progression and allow collateral circulation development 1

Immediate Diagnostic Work-Up Required

Obtain these studies emergently:

• Chest CT with contrast to identify empyema, fistula, pulmonary vein thrombosis, or abscess formation
• Chest radiograph to assess for new infiltrates, pleural effusion, or pneumothorax
• Arterial blood gas to quantify hypoxemia and assess for respiratory failure 4
• Complete blood count and inflammatory markers (WBC, CRP) to confirm infection
• Sputum culture and Gram stain to guide antibiotic selection
• Transoesophageal echocardiography if pulmonary vein thrombosis is suspected 1

Immediate Management Priorities

Respiratory Support

• Supplemental oxygen to maintain SpO2 >90% 4
• Monitor for need for non-invasive ventilation or intubation if respiratory distress worsens 4
• Avoid positive pressure ventilation if bronchopleural fistula is confirmed, as this can worsen air leak 3

Empiric Antibiotic Therapy

• Start broad-spectrum intravenous antibiotics immediately covering hospital-acquired pathogens (e.g., piperacillin-tazobactam or meropenem plus vancomycin)
• Adjust based on culture results and clinical response
• Post-operative infections can rapidly progress to sepsis in compromised patients 3

Anticoagulation Consideration

• If pulmonary vein thrombosis is confirmed, initiate therapeutic anticoagulation with heparin 1
• This allows development of collateral circulation through intercostal veins and prevents lung gangrene 1

Critical Pitfalls to Avoid

• Do not delay hospital transfer while awaiting outpatient imaging—this patient needs immediate evaluation 2
• Do not attribute symptoms to "normal post-operative recovery"—two weeks post-bilobectomy, patients should be improving, not deteriorating with new purulent sputum 2
• Do not miss bronchopleural fistula—the bubbling sensation is a specific clue that requires surgical consultation 3
• Do not overlook pulmonary vein thrombosis—though rare, it is specifically associated with bilobectomy and requires anticoagulation rather than surgery 1

Surgical Consultation

• Immediate thoracic surgery consultation is mandatory
• Empyema may require chest tube drainage or video-assisted thoracoscopic surgery (VATS) debridement
• Bronchopleural fistula may require surgical repair if conservative management fails
• Completion pneumonectomy is a last resort for uncontrolled complications 5

Prognosis and Expected Course

• With prompt diagnosis and treatment, most post-bilobectomy infections respond to antibiotics and drainage 1
• Pulmonary vein thrombosis treated with anticoagulation allows collateral circulation development within 35 days 1
• Delayed treatment significantly increases mortality risk from sepsis, respiratory failure, or thrombotic complications 2

Bottom line: This patient needs emergency department evaluation within hours, not days. The combination of bubbling sensation, purulent sputum, and severe dyspnea two weeks post-bilobectomy represents a surgical emergency until proven otherwise.