Bronchial Tear Associated With Convex Probe Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: An Unusual Complication

Abstract

SESSION TITLE: Procedures SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: The convex probe endobronchial ultrasound (CP-EBUS) is a fiberoptic bronchoscope with a significantly different configuration from a conventional bronchoscope. CP-EBUS has been touted to be a low risk procedure, with complications such as infection and pneumothorax. However, several inherent limitations could potentially cause other complications such as mucosal injury. These limitations include an oblique direction of view, decreased field of view and depth of field, as well as a rigid tip that extends beyond the camera and visualized area. We report a case of a patient who developed a bronchial tear and pneumothorax during the course of an evaluation with CP-EBUS. CASE PRESENTATION: A 62 year-old Caucasian male presented to an outside hospital with complaints of hemoptysis. He was noted to have complete opacification of the left lung on chest radiograph. He underwent bronchoscopy with findings of blood, clots, as well as distal endobronchial tumor. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) of lymphadenopathy was performed. Upon withdrawing the CP-EBUS, a left mainstem bronchus full-thickness tear of the posterior wall was identified, proximal to the distal lesion. This was felt to occur during CP-EBUS inspection. The patient was emergently transferred to our center for evaluation. A chest tube was placed for moderate pneumothorax upon his admission to the intensive care unit. Biopsies from the initial bronchoscopy resulted as squamous cell carcinoma. Repeat bronchoscopy demonstrated endobronchial tumor involvement in RC1 and main carina as well as near total obstruction of the left upper and lower lobes. The patient began external beam radiation with plans for outpatient chemotherapy. DISCUSSION: CP-EBUS is widely used for the evaluation of central lesions. However, there is suspected increased risk of mucosal injury due to its limited visibility, depth perception, and rigid tip, particularly in friable tissue. We feel such complications may go unrecognized. A review of the literature reveals only two cases reported with similar injury. This case demonstrates that CP-EBUS can lead to mucosal injury, even by an experienced operator. CONCLUSIONS: Mucosal airway trauma associated with CP-EBUS can occur and may go unrecognized. Risk of airway injury should be considered and conveyed to patients in obtaining consent for CP-EBUS. Reference #1: Eapen, G.A. et al. Complications, Consequences, and Practice Patterns of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration. CHEST. 2013; 143(4):1044-1053. DISCLOSURE: The following authors have nothing to disclose: Rishi Sehgal, Paul Branca, Naveed Sheikh No Product/Research Disclosure Information