ENDOBRONCHIAL VALVES FOR THE MANAGEMENT BRONCHOPLEURAL FISTULA, EMPYEMA, AND TRAPPED LUNG

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bronchopleural fistula (BPF) is a rare complication of necrotizing pneumonia. It is associated with significant morbidity, mortality, and prolonged hospitalization1. Our case describes the bronchoscopic and pleural management approach of BPF that was complicated by empyema and trapped lung. CASE PRESENTATION: A 40-year-old woman who is diabetic and smoker was admitted to the intensive care unit for hypoxemic respiratory failure and septic shock. She was diagnosed with multifocal pneumonia secondary to methicillin-sensitive staphylococcus aureus. On day 2, a pigtail was placed for left tension pneumothorax. Despite successful extubation on day 8, a continuous air leak persisted. She remained febrile, septic with leukocytosis while on antibiotics. Chest CT scan revealed multifocal necrotizing pneumonia with left lung abscesses, left-sided empyema, left upper lobe (LUL) BPF, and right lung consolidations (Fig1). A posterior, left-sided 14F chest tube was placed, which drained frank pus. On day 19, the air leak was localized in the LUL and left lower lobe (LLL) anteromedial using balloon occlusion during Bronchoscopy. 8ml of CoSeal surgical sealant was administered to occlude the LUL segments and LLL anteromedial segment. The air leak completely resolved but recurred two days later. On repeat Bronchoscopy, 2 Zephyr endobronchial valves (EBV) were placed in the LUL bronchus and the LLL anteromedial segment which resolved the air-leak (Fig2). The left pleural space remained complicated with trapped lung, air-fluid level, and purulent drainage through the chest catheters. Two 20 French open chest tubes were placed to drain empyema, -40 cmH2O suction was applied to four chest tubes for two weeks to manage the trapped lung and prevent endobronchial spillage of the purulent secretions. Repeat CT chest showed improvement in left lung aeration and small residual hydropneumothorax. The chest tubes were removed on day 57, and she was discharged to acute rehabilitation. She was released home and remained asymptomatic at the three-month follow-up. DISCUSSION: The gold standard for the treatment is surgical management by video-assisted thoracoscopic surgery (VATS) or thoracotomy, but it can be challenging in the setting of active infection. Our case demonstrates the successful use of EBVs as a minimally invasive treatment option for persistent air leak that is complicated by empyema and trapped lung. EBVs allow retrograde passage of air and infected secretions while blocking anterograde airflow which permits the fistulous tract to heal. Applying high suction to all chest tubes was imperative in creating a sterile pleural space. The alternative management was an open-window thoracostomy and is usually associated with significant morbidity, mortality, and poor quality of life. CONCLUSIONS: The bronchoscopic management of BPF complicated by empyema and trapped lung may be successful in poor surgical candidates. Reference #1: 1] M. Lois, M. Noppen, Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management, Chest 128 (2005) 3955–3965. DISCLOSURES: No relevant relationships by Kassem Harris, source=Web Response No relevant relationships by Anant Jain, source=Web Response no disclosure on file for Daniel Katzman; No relevant relationships by Anna Shengelia, source=Web Response