Abstract
BackgroundThe treatment of persistent air leak is a challenge. Herein, we reported the combined intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy to seal off an alveolar pleura fistula developed following necrotizing pneumonia in high-risk patient.Case presentationA 74-year-old man was intubated in emergency for acute ischemic stroke. Percutaneous dilatational tracheostomy was then performed, and 15 days later patient returned to spontaneous breathing. However, he developed alveolar pleural fistula following necrotizing pneumonia with persistent air leaks. The intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy sealed off the alveolar pleura fistula after that other endoscopic treatments as bronchial valve and intrabronchial fibrin glue application had failed.ConclusionsOur strategy is safe and easy to reproduce. It represents an additional method in the armamentarium of the physicians for the management of PAL when all standard strategies are unfeasible or fail.
Highlights
Persistent air leak (PAL) is a frustrating clinical condition due to a pathological communication between the lung and pleural space [1]
We reported a new approach as the intrabronchial and intrapleural injection of Fibrin Glue (FG) using fiber bronchoscopy to seal off Alveolar Pleural Fistula (APF) developed following necrotizing pneumonia in high-risk patient
Fiber bronchoscopy, introduced through the chest drainage, explored the pleural cavity and showed a small APF (Fig. 3a) that was marked by methylene blue following intrabronchial injection of the blue solution within Right B9 (RB9) segment (Fig. 3b)
Summary
The treatment of the present case was challenging. Conservative treatment with chest drainage failed to resolve air leaks since dense pleural adhesions trapped the right lower lobe, and prevented its expansion. We closed the RB9 segment with FG [2, 3], and this procedure failed as fibrin clot dislocated probably due to frequent airway aspirations. Kinoshita et al [5], and Shrestha et al [6] previously treated PAL by intrapleural injection of FG via a chest tube In both cases, the FG was blindly injected within pleural cavity, while, in the present, the APF was sealed off under bronchoscopic view. From a technically point of view, we recommend: (i) the use of large chest tube (≥ 28 French) to make easy the insertion and the handle of the fiber bronchoscopy; (ii) the careful exploration of pleural cavity to prevent additional injury of frail parenchyma; and (iii) the use of a dedicated double lumen catheter (Duplocath 180, Baxter AG, Vienna) for FG application. Our impression should be corroborated by future, large experiences
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