Large Bronchopleural Fistula Research Articles

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

FROM ALL LUNG TO ALL AIR: A CASE OF IATROGENIC FUNCTIONAL PNEUMONECTOMY

Translated article] Combined Endoscopic Treatment for the Closure of a Large Bronchopleural Fistula

Translated article] Combined Endoscopic Treatment for the Closure of a Large Bronchopleural Fistula

Abstract No.: ABS0615: Anaesthesia management of bilateral bronchopleural fistula for repair

Background and Aims:Bronchopleural fistula (BPF) poses ventilatory challenges during general anaesthesia (GA). Without repair of large BPF, patient’s condition is unlikely to improve. Hence thoracic surgery in these patient is a challenging task. Coronavirus disease 2019 (COVID-19) pandemic, has caused immense morbidityincluding pulmonary sequelae pulmonary complications such as BPF. Perioperative strategies included to maintaining adequate ventilation and haemodynamics.Methods:We present anaesthesia management of five cases, who developed bilateral significant BPF as post COVID-19 sequelae. Conservative treatment with bilateral ICD did not reduce the BPF leak. Hence, surgical closure of BPF was planned. Maintaining adequate ventilation was challenging task. Regional blocks are considered safer alternative in patients with pulmonary disease. Erector spinae blocks (ESP) was performed. Ventilatory and haemodynamic parameters were measured. Pain score and patient comfort was also recorded.Results:Out of five patients , four patients received ESP block and one patient had haemodynamic instability in intensive care unit so,the patient was operated under GA Table 1. Desaturation during positioning were noted in only one patient. Inotropes to maintain haemodynamics were required in two patients . All patients managed under ESP block were comfortable during intraoperative period.Conclusion:ESP block was found to be a a safer option for perioperative management in BPF repair in these patients of post COVID-19 sequelae .Table 1Perioperative data of patientsESP Block (n=4)GA (n=1)Desaturation (n patients)01Inotropic requirement (n patients)11Duration of Surgery (h)1.5 2Opioid Requirement(µg)200 500 ESP: Erector spinae plane, GA: General anaesthesia

Endoscopic Bronchopleural Fistula Repair Using Autologous Fat Graft

Bronchopleural fistulas (BPFs) represent a rare catastrophic complication of pulmonary resection and carry a high mortality rate. Surgical treatments of BPF are often technically difficult and can be tolerated only by a limited number of patients, while less invasive endoscopic approaches show variable success rates, mainly related to the size of the fistula. In this report, we describe the successful treatment of a large BPF by means of endoscopic autologous fat implantation; we also discuss the technical details of this surgical procedure.

OLEOTHORAX: PULMONARY PLOMBAGE

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plombage (extra-pleural pneumonolysis) is a surgical treatment method used to treat cavitary lesions of the lung in patients with pulmonary tuberculosis (TB) during 1930–50s before the introduction of anti-TB chemotherapy by creating a cavity surgically under the ribs in the chest wall and filling the space with inert material [1]. The materials used in this procedure are acrylic balls, fat, wax, rubber, and mineral oil (Oleothorax). Rarely, Plombage is used to seal a large bronchopleural fistula that causes refractory pneumothorax, with only one reported case in the literature [2]. We present another case of Pulmonary Plombage (Oleothorax) used in successfully treating refractory pneumothorax. CASE PRESENTATION: A 62-year-old man with a history of hypertension and symptomatic bradycardia requiring a permanent pacemaker came in with worsening shortness of breath associated with decreased exercise tolerance and orthopnea. The examination was remarkable for pan systolic murmur at the apex, jugular venous distention, and decreased breath sounds in the right lung base. Chest radiograph (Image 1) revealed cardiomegaly and a pleural-based rounded mass in the right pleural space inferiorly. Computed tomography (Image 2) showed a loculated cystic mass (label A) (13x9x10 cm) measuring slightly above water density and apical bullae. An echocardiogram revealed severe left atrial and left ventricular dilation with an ejection fraction of 55% and prolapse of the anterior leaflet of the mitral valve (MV) with severe mitral regurgitation (MR). Pulmonary service was consulted for loculated cystic mass in the lung, upon further questioning, the patient mentioned he had lung surgery in 1993 due to recurrent pneumothorax, which was found to be Pulmonary Plombage. He was started on intravenous loop diuretics for congestive heart failure secondary to MR with improvement in symptoms. DISCUSSION: We presented the modern imaging description of a Plombage thoracoplasty performed to treat refractory pneumothorax with an uncomplicated outcome 28 years after surgery. A new method to treat pneumothorax due to a large cavity with a bronchopleural fistula. The utility of Pulmonary Plombage to seal a large bronchopleural fistula causing refractory pneumothorax has not been studied, with only one case report [2] in the literature where they used pericardial fat pad as Plombage to successfully treat refractory pneumothorax without complications after 48 years. This technique involves complications like hemorrhage, infection, fistulization to the skin. Radiographic characters depend on the material used in the Plombage treatment. The cystic mass measuring slightly above water density seen in our patient was filled with mineral oil (Oleothorax). CONCLUSIONS: Pulmonary Plombage, a historical treatment used to treat cavitary lesions in tuberculosis patients, can be used effectively in treating refractory pneumothorax. REFERENCE #1: Namana V, Gupta SS, Sarasam R, Mathur P: Historical TB treatment—Plombage. QJM An Int J Med. 2017, 110:191. 10.1093/qjmed/hcw213 REFERENCE #2: Nakano T, Tsubochi H, Minegishi K, Endo S: Pericardial fat pad plombage for pulmonary cavity causing massive air leakage. Surg Case Reports. 2020, 6:156. 10.1186/s40792-020-00917-7 DISCLOSURES: No relevant relationships by Akshay Avula, source=Web Response No relevant relationships by Elias Chuki, source=Web Response No relevant relationships by Raja Jadav, source=Web Response No relevant relationships by Harry Sequeira gross, source=Web Response

Time controlled adaptive ventilation\u2122 as conservative treatment of destroyed lung: an alternative to lung transplantation

BackgroundAcute respiratory distress syndrome (ARDS) often requires controlled ventilation, yielding high mechanical power and possibly further injury. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) can be used as a bridge to recovery, however, if this fails the end result is destroyed lung parenchyma. This condition is fatal and the only remaining alternative is lung transplantation. In the case study presented in this paper, lung transplantation was not an option given the critically ill state and the presence of HLA antibodies. Airway pressure release ventilation (APRV) may be valuable in ARDS, but APRV settings recommended in various patient and clinical studies are inconsistent. The Time Controlled Adaptive Ventilation (TCAV™) method is the most studied technique to set and adjust the APRV mode and uses an extended continuous positive airway pressure (CPAP) Phase in combination with a very brief Release Phase. In addition, the TCAV™ method settings are personalized and adaptive based on changes in lung pathophysiology. We used the TCAV™ method in a case of severe ARDS, which enabled us to open, stabilize and slowly heal the severely damaged lung parenchyma.Case presentationA 43-year-old woman presented with Staphylococcus Aureus necrotizing pneumonia. Progressive respiratory failure necessitated invasive mechanical ventilation and VV-ECMO. Mechanical ventilation (MV) was ultimately discontinued because lung protective settings resulted in trivial tidal volumes. She was referred to our academic transplant center for bilateral lung transplantation after the remaining infection had been cleared. We initiated the TCAV™ method in order to stabilize the lung parenchyma and to promote tissue recovery. This strategy was challenged by the presence of a large bronchopleural fistula, however, APRV enabled weaning from VV-ECMO and mechanical ventilation. After two months, following nearly complete surgical closure of the remaining bronchopleural fistulas, the patient was readmitted to ICU where she had early postoperative complications. Since other ventilation modes resulted in significant atelectasis and hypercapnia, APRV was restarted. The patient was then again weaned from MV.ConclusionsThe TCAV™ method can be useful to wean challenging patients with severe ARDS and might contribute to lung recovery. In this particular case, a lung transplantation was circumvented.

Therapeutic closure of bronchopleural fistulas using ethanol.

Bronchopleural fistula (BPF) leading to persistent air leak (PAL), be it a complication of pulmonary resection, radiation, or direct tumor mass effect, is associated with high morbidity, impaired quality of life, and an increased risk of death. Incidence of BPF following pneumonectomy ranges between 4.4% and 20% with mortality ranging from 27.2% to 71%. Following lobectomy, incidence ranges from 0.5% to 1.5% in reported series. BPFs are more likely to occur following right-sided pneumonectomy, while patients undergoing bi-lobectomy were more likely to suffer BPF than those undergoing single lobectomy. In addition to supportive care, including appropriate antibiotics and nutrition, management of BPF includes pleural decontamination, BPF closure, and ultimately obliteration of the pleural space. There are surgical and bronchoscopic approaches for the management of BPF. Surgical interventions are best suited for large BPFs, and those occurring in the early postoperative period. Bronchoscopic techniques may be used for smaller BPFs, or when an individual patient is no longer a surgical candidate. Published reports have described the use of polyethylene glycol, fibrin glues, autologous blood products, gel foam, silver nitrate, and stenting among other techniques. The Amplatzer device, used to close atrial septal defects has shown promise as a bronchoscopic therapy. Following their approval under the humanitarian device exemption program for treatment of prolonged air leaks, endobronchial valves have been used for BPF. No bronchoscopic technique is universally applicable, and treatment should be individualized. In this report, we describe two separate cases where we use an Olympus© 21-gauge EBUS-TBNA (endobronchial ultrasound–transbronchial needle aspiration) needle for directed submucosal injection of ethanol leading to closure of the BPF and subsequent successful resolution of PAL.

A non-surgical option in large bronchopleural fistulas: Bronchoscopic conical stent application.

This study aims to compare the results of the open surgical approach versus endobronchial conical stent application in the treatment of extensive fistulas. Between December 2004 and April 2016, a total of 36 patients (34 males, 2 females; mean age 59.6±8.1 years; range, 40 to 72 years) with a bronchopleural fistula of ≥8 mm in diameter and underwent either conventional open surgery with stump-supported intercostal muscle flap or endobronchial ultra-flex expandable stenting were retrospectively analyzed. The demographic and clinical characteristics of the patients, operative data including the length of hospital stay, thoracic drainage time, and early mortality, and survival data were recorded. The mean hospitalization time was 17.4±4.5 days for the bronchoscopic group and 22.5±6.7 days for the invasive surgery group (p=0.026). The median time to removal of thoracic drains was 15 (range, 10 to 30) days for the bronchoscopic group and 26 (range, 14 to 55) days for the surgical group (p=0.027). Early mortality rates of both approaches were in favor of the bronchoscopic approach (χ2=7.058; p=0.008). Two-year survival rate was 76.47% (n=13) in the bronchoscopic group and 70% (n=7) in the surgical group. There was no statistically significant difference in the survival rates between the two groups (χ2=0.132; p=0.716). Our study results suggest that bronchoscopic approach can be the first choice in the treatment algorithm of fistulas with a diameter of ≥8 mm presenting with empyema in selected cases.

Pericardial fat pad plombage for pulmonary cavity causing massive air leakage

BackgroundSecondary pneumothorax after chemotherapy for a malignant pulmonary tumor is a complication from a large cavity causing refractory pneumothorax.Case presentationA 61-year-old man was referred due to prolonged air leakage from a pulmonary cavity that developed after treatment for pulmonary metastases from renal cell carcinoma. As air leakage continued after thoracic drainage and endobronchial occlusion, we planned thoracoscopy-assisted surgery. Intraoperatively, a large cavity opening to the pulmonary cavity was found in the left upper lobe. As it was difficult to repair the fistula using staplers or direct sutures because the pleura around the cavity was thick and hard, we attempted to plombage the cavity with a pericardial fat pad. After the operation, air leakage immediately disappeared and no recurrence of the pneumothorax was found.ConclusionThis novel method can be useful to seal a large bronchopleural fistula that causes refractory pneumothorax.

Intrathoracic negative pressure therapy and/or endobronchial valve for pleural empyema minimal invasive management: case series of thirteen patients and review of the literature.

IntroductionIntrathoracic negative pressure therapy is an adjunct to standard methods of complex empyema management in debilitated patients. Nevertheless, the use of endoscopic one-way endobronchial valves to successfully close large bronchopleural fistulas in patients with advanced pleural empyema has been described in only a few case reports.AimTo present our experience in managing complex pleural empyema using thoracostomy with intrathoracic negative pressure therapy and/or endobronchial valve implantation.Material and methodsWe retrospectively analyzed data from 13 consecutive patients (11 men, mean age: 56 years, range: 38–80 years) who were treated for pleural empyema using thoracostomy with intrathoracic negative pressure therapy and/or endobronchial valve implantation between October 2015 and November 2017.ResultsThe control of empyema was satisfactory in 12 patients; however, 1 patient died from sepsis-related multiorgan failure despite complete cessation of air leak on day 9 after endobronchial valve implantation. The overall success rate for the final closure of the chest wall was 9/12 patients (75%): in 5 patients, the wall closed spontaneously, and in 4, the wall was closed using thoracomyoplasty.ConclusionsThoracostomy with intrathoracic negative pressure therapy, endobronchial valve implantation with tube drainage, and a combination of the two could adequately manage patients with pleural empyema with or without a persistent air leakage fistula.

Bronchopleural Fistula Closure with Vascular Plug and Intrapleural Glue Administration

The presence of communication between a mainstem, lobar, or segmental bronchus and the pleural place is called a bronchopleural fistula (BPF). It is commonly caused as a result of postoperative complication of lung resection surgeries, chemotherapy or radiotherapy for lung cancer, persistent spontaneous pneumothorax, empyema, lung abscess, and tuberculosis. A 20-year-old male underwent decortication for diffuse right-sided tuberculous pleural thickening. Postsurgery, he developed BPF. He underwent open thoracic surgery for BPF closure. However, he continued to have air leak and persistent empyema. Repeat evaluation revealed a large BPF at the anterior segment of the right upper lobe on computed tomography chest, which was confirmed on bronchoscopy. He underwent bronchoscopic closure (under fluoroscopic guidance) of BPF with a 6 mm × 7 mm vascular plug successfully. Major air leak stopped and lung expansion increased on chest X-ray. However, small air leaks (alveolar-pleural fistula) persisted. Later, he was subjected to intrapleural diluted fibrin glue administration (fibrinogen + aprotinin + thrombin) via a chest tube at bedside. Application of diluted fibrin glue through the chest tube succeeded in completely sealing the small air leaks. Radiologically, there was no further lung collapse and the pleural space was nearly obliterated.

Successful Treatment with Fenestration and Multi-professional Intervention for a Large Bronchopleural Fistula

Successful Treatment with Fenestration and Multi-professional Intervention for a Large Bronchopleural Fistula

Seorang Perempuan Perokok Tembakau dan Mariyuana dengan Pneumotoraks Spontan Primer Akibat Blep Multipel yang Pecah

Background: Primary spontaneous pneumothorax (PSP) can be caused by a ruptured blep emfisematus subpleural. People who smoke tobacco and marijuana simultaneously arise PSP will be more risky than just smoking tobacco. Pneumothorax in cannabis smokers may occur due to coughing at the time was holding their breath, when they were smoking marijuana. Case: We report the case of 33-year-old woman with recurrent shortness of breath as a result of primary spontaneous pneumothorax in the right hemithorax. The patient’s tobacco and marijuana smokers. Patients had undergone previous pleurodesis. Chest X-ray picture of the lines conveniently indicates lung collapse and air-fluid level in the right hemithorax. Thoracoscopic showed a large bronchopleural fistula. During thoracotomy found one bronkopeural fistula, three large blep, and more than 15 small blep. Then do the suturing of fistula and blep. Patients recover in a short time and in good condition during treatment. Conclusion: Tobacco and marijuana smoking is a risk factor that is synergistic to the occurrence of primary spontaneous pneumothorax. These patients consume both are irregular but have resulted in multiple blep that can rupture and cause a pneumothorax.

Effective Neurally Adjusted Ventilatory Assist (NAVA) Ventilation in a Child with a Large Bronchopleural Fistula

Effective Neurally Adjusted Ventilatory Assist (NAVA) Ventilation in a Child with a Large Bronchopleural Fistula

Pedicled gastric seromuscular patch for one-stage closure of a bronchopleural fistula: a case report

BackgroundOne-stage closure and fenestration are the available surgical options for bronchopleural fistula (BPF). One-stage closure may be applicable in cases with favorable infection control. Closing the bronchopleural stump is difficult due to thick adhesion caused by inflammation and a high risk of pulmonary artery injury. We report the successful closure of a BPF using a gastric seromuscular patch with an omental pedicle flap.Case presentationA 73-year-old man underwent right lower lobectomy with ND2a-2 lymph node dissection for lung adenocarcinoma. He was admitted to a local hospital for pneumonia. Three days after admission, his thoracic cavity was drained and a BPF was suspected. During the primary operation, the latissimus dorsi muscle and anterior serratus muscle were dissected via posterolateral incision, and we decided to close the fistula using the gastric seromuscular layer and omental pedicle flap. The patient was discharged 20 days after surgery. After 2 years, he has not had cancer recurrence and currently leads an active life.ConclusionsThis method provided immediate airtight closure and luminal opening of the middle bronchus in our patient with a large BPF and appeared superior to using the omentum alone. This procedure is useful for one-stage closure and does not require fenestration in cases with favorable infection control.

Large Bronchopleural Fistula After Surgical Resection: Secret to Success

Large Bronchopleural Fistula After Surgical Resection: Secret to Success Isabelle Delanote, MD, Werner Budts, MD, PhD, Paul De Leyn, MD, PhD, Christophe Dooms, MD, PhD* Department of Respiratory Diseases, University Hospitals, Katholieke Universiteit, Leuven, 3000 Leuven, Belgium Department of Cardiology, University Hospital, Katholieke Universiteit, Leuven, 3000 Leuven, Belgium Department of Thoracic Surgery, University Hospitals, Katholieke Universiteit, Leuven, 3000 Leuven, Belgium

Getting the Wind Knocked out of Your Chest: A Case of Endobronchial Valve Placement for Bronchocutaneous Fistula Following Thoracoplasty for Pulmonary Tuberculosis and Aspergillosis

SESSION TITLE: Procedures Case Report Posters SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Bronchopleural fistula (BPF) is cause for significant morbidity and mortality following pulmonary resection, complicated pleural infection or pneumothorax. Several methods exist for the treatment of BPF ranging from conservative methods to more invasive surgical correction. Endobronchial valve (EBV) placement is a promising minimally invasive technique for poor surgical candidates. CASE PRESENTATION: A 61-year-old male was diagnosed with pulmonary tuberculosis following a trip to Mexico in 2013 and initiated on RIPE therapy, later converted to Rifampin and Isoniazid after sputum clearance. His course was complicated by pulmonary aspergillosis and empyema with significant left upper lobe (LUL) destruction requiring thoracoplasty with Eloesser flap. Several months later he was hospitalized for sepsis and found to have a BPF for which he underwent muscle flap closure. Upon follow-up, he was noted to have a large extrapulmonary air pocket that varied with inspiration. A large BPF between the LUL and lingula was confirmed by bronchoscopy. He was deemed to be a poor repeat surgical candidate due to suboptimal nutritional status and debility so a less invasive intervention was favored. In December 2014 the patient underwent bronchoscopic placement of a removable 7.0mm Spiration® IBV valve. At one month follow up there was significant reduction in the extrapulmonic air accumulation (shown). DISCUSSION: Endobronchial valves were first designed for bronchoscopic lung volume reduction in patients with severe emphysema and air trapping. More recently they were approved by the FDA under the Humanitarian Device Exemption for use in persistent air leaks (PAL) following lung resection. Off-label use for BPF or PAL secondary to suppurative lung infection or spontaneous pneumothorax have become increasingly popular owing to the minimally invasive technique. One-way EBV's work by blocking airflow distal to the valve promoting atelectasis and healing of the BPF while permitting clearance of airway secretions without affecting valve migration. CONCLUSIONS: This is a novel report of the successful use of one-way EBV for a large proximally located BPF after definitive closure was attempted with a muscle flap. Further trials are needed to establish guidelines regarding indications for use, optimal duration and prognosis after placement in such situations. Reference #1: Giddings, O. et al. Endobronchial valve placement for the treatment of bronchopleural fistual: a reivew of the current literature. Curr Opin Pulm Med. 2014. 20:347-51. DISCLOSURE: The following authors have nothing to disclose: Amber Oberle, Khalil Diab, Lorenzo Zaffiri, Aliya Noor Endobronchial valve (EBV) placement for bronchopleural fistulas or persistent air leaks after spontaneous pneumothorax, suppurative chest infection and failure of conventional therapy is currently regarded as off-label and not approved by the FDA. EBV's were originally designed for bronchoscopic lung volume reduction in patients with severe heterogeneous emphysema but have not been FDA approved for this indication. In 2006, The FDA did approved the use of EBV's under the Humanitarian Device Exemption program for patients with persistent air leaks after lung parenchymal resection.

Closure of a large bronchopleural fistula by omentoplasty and free myocutaneous latissimus dorsi muscle flap

The treatment of post-pneumonectomy bronchopleural fistula requires both closure of the fistula and control of the infection usually by obliteration of the thoracic cavity. A 53-year-old man developed a large airway defect (4 × 2 cm) after right pneumonectomy performed for lung cancer. To close such a large defect a two-stage operation consisting of omentoplasty and free lattisimus dorsi muscle flap transposition was performed. This report illustrates the feasibility of overcoming this demanding complication with collaboration of plastic surgery.

Endobronchial Closure of Recurrent Bronchopleural and Tracheopleural Fistulae by Two Amplatzer Devices

We present a case of right pneumonectomy after induction chemotherapy complicated by a large bronchopleural fistula and empyema two weeks after surgery. The patient was treated surgically by transsternal transpericardial bronchopleural fistula closure and open window thoracoplasty. Thereafter, two new fistulae developed, one in the right main bronchial stump and one in the accessory tracheal bronchus. The two Amplatzer devices that were originally designed for transcatheter closure of cardiac defects were successfully used for closure of the bronchopleural fistulae.

Successful Closure of Bronchopleural Fistula With Xeroform Dressing

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree, and is associated with significant morbidity and mortality. Treatment options for BPF include surgical closure and medical therapy. In an unstable patient, invasive surgical intervention is not an option. In this article, we report the case of a 61-year-old man who developed pneumothorax with a large BPF after a bronchoscopic resection of a malignant endobronchial lesion. We inserted a piece of 1.5×1.5-cm Xeroform dressing to seal the massive air leak with successful closure of the BPF. To our knowledge, this is the first report of successful closure of a massive BPF with Xeroform dressing in an acutely decompensating patient.