UNIQUE CASE OF ENDOBRONCHIAL VALVE IN TB BRONCHOPLEURAL FISTULA

Abstract

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: A bronchopleural fistula (BPF) is a pathological connection between bronchial tree and the pleural space. BPF is a well-known complication of pulmonary tuberculosis (PTB). Endobronchial valve (EbV) are conventionally used to treat persistent air leaks (PAL) in the setting of non-surgical bronchopleural fistula. EbV are not routinely used in BPF secondary to active PTB. We describe a unique case where EbV was used to treat BPF secondary to active cavitatory pulmonary tuberculosis CASE PRESENTATION: A 30-year-old Spanish-speaking female, emigrated from Honduras 5 years ago presented to the emergency department with worsening productive cough and anorexia for two months. On admission patient was noted to be in respiratory distress and saturating 88% on room air. She once cachectic had poor inspiratory effort and bilateral rhonchorous breath sounds. Chest imaging was significant for bilateral upper lobe thick walled cavitatory lesions. Mycobacterium tuberculosis without rifampin resistance was detected, and patient was started on antituberculous therapy. On day 7 patient developed acute respiratory distress secondary to large right-side pneumothorax requiring chest tube placement. Patient required mechanical ventilation for hypercarbic respiratory failure, felt secondary to significant air leak. Bronchoscopy with balloon occlusion was performed, BPF with air leak was identified in right upper lobe with complete disappearance of air leak on occlusion of all three segments of right upper lobe (RUL). On day14 patient underwent endobronchial valve placement with complete occlusion of RUL. The hypercapnia, hypoxia improved, and patient stabilized clinically. Unfortunately, patient had complicated ICU course with failure to thrive and venous thromboembolism. On day 35 family requested terminal extubation and comfort care. DISCUSSION: There is very limited literature on utility and safety of EbV in patients with BPF and PAL secondary to active cavitatory PTB. Since their first description in 2005 by Snell (1), EbV have been in use for more than a decade now. The main indication of EbV is non-surgical management of BPF and PAL. PAL have been associated with significant morbidity, mortality and prolonged hospital stay(2). There is recent literature in multidrug resistant tuberculosis where EbV was used safely to treat cavernous tuberculosis with improved cavity closure and bacteriological conversion (3). In our patient the main reason for EbV placement was to improve minute ventilation and hypercapnia secondary to PAL. Endobronchial valve placement stabilized the clinical status in our patient without any associated adverse events. CONCLUSIONS: We need more literature and randomized controlled trials to evaluate safety and long-term complications of EbV in pulmonary tuberculosis associated BPF. Our case highlights that EbV could be a safe option for BPF in patients with active pulmonary tuberculosis. Reference #1: Snell, G., Holsworth, L., Fowler, S., Eriksson, L., Reed, A., Daniels, F.. (2005) Occlusion of a broncho-cutaneous fistula with endobronchial one-way valves. Ann Thorac Surg 80: 1930–1932. Reference #2: Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128:3955–65. Reference #3: Denis Krasnov, Yana Petrova, Sergei Skluev, Irina Felker, Vladimir Krasnov, Nikolay Grischenko. Endobronchial valve in complex treatment of patients with destructive pulmonary TB/HIV co-infection.European Respiratory Journal 2016 48: PA775; https://doi.org/10.1183/13993003.congress-2016.PA775 DISCLOSURES: No relevant relationships by Sean Dikdan, source=Web Response No relevant relationships by Boyd Hehn, source=Web Response No relevant relationships by MRINALINI VENKATA SUBRAMANI, source=Web Response