CLOSURE OF A BRONCHOPLEURAL FISTULA WITH ONE-WAY ENDOBRONCHIAL VALVES WHILE ON HIGH-FREQUENCY OSCILLATORY VENTILATION

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A bronchopleural fistula (BPF) is an abnormal sinus tract between the tracheobronchial tree and the pleural space whose presence is associated with increased morbidity, mortality and extended hospital duration. Additionally, a large airway defect can result in refractory hypercapnia rendering periprocedural ventilation exceedingly difficult. Preferred definitive management is surgical resection. However, for the non – surgical candidate a handful of bronchoscopic and pleural interventions, including compassionate placement of one – way valves, have been successfully described for the treatment of a persistent BPF. CASE PRESENTATION: A 25 – year old male with restrictive lung disease secondary to severe muscular dystrophy was admitted to a surgical ICU after a difficult intubation resulting in an emergent cricothyroidotomy and placement of two unilateral surgical chest tubes. The patient’s underlying lung disease combined with intra-parenchymal placement of one of the chest tubes resulted in mixed respiratory failure. Multiple modes of conventional ventilation with neuromuscular blockade were trialed with persistent life threatening hypercapnia prior to being stabilized on a High – Frequency Oscillatory Ventilator (HFOV). His clinical course was complicated by bacteremia, fungemia and a large continuous air-leak. On bronchoscopy, the right upper lobe (RUL) was identified as the anatomic origin of the defect following occlusion with a 5.5 Fr Fogarty Balloon catheter and resolution of the air leak. Definitive management was attempted by placement of four one – way Spriation endobronchial values within the RUL segments while concurrently on HFOV. Significant decrement of the air leak was successfully obtained as well as improvement of his oxygenation and ventilation. DISCUSSION: Chest trauma, including inadvertent intra – parenchymal placement of a chest tube is a rare cause of a bronchopleural fistula. We describe a case of a BPF complicated by a large persistent air leak with initial management via ventilation on a high frequency oscillatory ventilator followed by a novel attempted at definitive treatment with placement of endobronchial values while concurrently on HFOV. CONCLUSIONS: Compassionate placement of endobronchial one – way vales can be safely executed while on HFOV for management of a severe BPF in non – surgical candidates. Reference #1: Gilbert, C. R., Casal, R. F., Lee, H. J., Feller-Kopman, D., Frimpong, B., Dincer, H. E., … Yarmus, L. B. (2016). Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage. The Annals of Thoracic Surgery, 101(5), 1891–1896. doi: 10.1016/j.athoracsur.2015.10.113 Reference #2: Keshishyan, S., Revelo, A. E., & Epelbaum, O. (2017). Bronchoscopic management of prolonged air leak. Journal of Thoracic Disease, 9(S10). doi: 10.21037/jtd.2017.05.47 Reference #3: Ha, D. V., & Johnson, D. (2004). High frequency oscillatory ventilation in the management of a high output bronchopleural fistula: a case report. Canadian Journal of Anesthesia/Journal Canadien Danesthésie, 51(1), 78–83. doi: 10.1007/bf03018553 DISCLOSURES: No relevant relationships by Rohini Chatterjee, source=Web Response No relevant relationships by Michal Sobieszczyk, source=Web Response No relevant relationships by Bryce Warren, source=Web Response No relevant relationships by Whittney Warren, source=Web Response