BRONCHOPLEURAL FISTULA? ENDOBRONCHIAL VALVES TO THE RESCUE

Abstract

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Bronchopleural fistula (BPF) is a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space. Most commonly seen as a complication of lung resection surgery with morbidity ranging from 25%-71%. Treatment of BPF primarily is surgical closure but might but bronchoscopic interventions can be considered in certain cases. Here we present a case of endobronchial valves (EBVs) being used as a bridge to surgery. CASE PRESENTATION: A 60-year-old man presented muscle weakness, anterior mediastinal mass and respiratory failure requiring intubation. Diagnosis of myasthenic crisis was made and he underwent three rounds of plasmapheresis. Subsequently, video assisted thoracoscopy with resection of the thymoma was done but the surgery was complicated with need for right pneumonectomy. On post-operative day 6, patient developed right sided tension pneumothorax requiring a 28 Fr chest tube placement resulting in continuous grade IV air leak. Chest CT scan revealed a right hydropneumothorax (Fig 1). Diagnostic bronchoscopy on day 10, showed absence of right main stem bronchus along with a 4mm bronchopleural fistula (Fig 2). Cultures from the bronchoscopy grew methicillin sensitive staphylococcus aureus and he was started on appropriate antibiotics. He continued to have PAL along with significant tidal volume loss which led to failed weaning on the ventilator. Unfortunately, he was deemed not a surgical candidate due to his ventilator dependence from pneumonia and poor nutritional status. On day 14, we repeated bronchoscopy and fibrin sealant was applied through a guide sheath, down the working channel which reduced the air leak but still persisted. Next day, bronchoscopy with deployment of size 5 spiration endobronchial valves was performed (Fig 3) which led to cessation of air leak and on day 20, patient was successfully weaned off ventilator support. Patient was treated for the empyema for 4 weeks and chest tubes were thereafter removed. He was then discharged to subacute rehabilitation after 57 days of hospitalization and 8 weeks later underwent surgical closure. DISCUSSION: BPF diagnosis and management requires a multidisciplinary approach. Patients with poor cardiopulmonary status, the risks of general anesthesia and surgical intervention pose a challenge. A variety of bronchoscopic options like EBVs, stents, ASD closure devices and occlusive material can be considered, primarily as temporizing measures. EBVs allow retrograde passage of air and infected secretions while blocking anterograde airflow. This reduces or stops the air leak and promotes healing. Their use in our patient allowed for weaning from high levels of oxygen support and liberation from mechanical ventilation. CONCLUSIONS: EBV placement is a minimally invasive procedure which can be performed to help with PAL associated with small BPF (<5mm) when surgery is not an option. REFERENCE #1: M. Lois, M. Noppen, Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management, Chest 128 (2005) 3955–3965. REFERENCE #2: Giddings O, Kuhn J, Akulian J. Endobronchial valve placement for the treatment of bronchopleural fistula: a review of the current literature. Curr Opin Pulm Med. 2014 Jul;20(4):347-51. doi: 10.1097/MCP.0000000000000063. PMID: 24811833. REFERENCE #3: Mahajan AK, Verhoef P, Patel SB, Carr G, Kyle Hogarth D. Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients. J Bronchology Interv Pulmonol. 2012;19(2):137-141. doi:10.1097/LBR.0b013e318251c897 DISCLOSURES: No relevant relationships by Tejaswi Nadig, source=Web Response