Case Report: Multifactorial weaning failure after lung transplantation in paraquat-induced pulmonary fibrosis: a case-based clinical review.

Introduction: Lung transplantation (LT) remains a rare but life-saving option for end-stage pulmonary fibrosis secondary to paraquat poisoning. However, the post-operative course can be complicated by prolonged ventilator dependence, particularly in patients with toxic lung injury who have received extended sedation and neuromuscular blockade. Case report: A 25-year-old male presented with acute paraquat intoxication and developed progressive respiratory failure despite standard decontamination and hemoperfusion. He underwent bilateral LT after bridging with extracorporeal membrane oxygenation (ECMO). Following surgery, although gas exchange was satisfactory, repeated extubation attempts failed due to respiratory muscle weakness. Through a structured, multidisciplinary protocol combining serial neuromuscular assessment, individualized rehabilitation, and gradual ventilator weaning, successful extubation was achieved on post-operative day 12. The patient was discharged on day 48 with stable graft function. A review of 15 previously reported paraquat-related LT cases revealed recurring challenges in transplant timing, ECMO bridging, and respiratory recovery. Conclusion: This case highlights that in paraquat-induced toxic lung injury, successful ventilator liberation after LT depends on early recognition of neuromuscular dysfunction and integration of targeted rehabilitation within a multimodal, individualized care framework rather than relying solely on oxygenation parameters.