INTRODUCTION: Bronchopleural fistula (BPF) is a condition that results from numerous etiologies and typically occurs in the setting of multiple comorbid conditions that complicate the evaluation and treatment of a patient. Central BPF's are typically a result of pneumonectomy or trauma and can usually be visualized with bronchoscopy, whereas, peripheral BPF's usually occur in the setting of suppurative lung infection, neoplasm, or trauma. Large peripheral BPF's can be localized with computed tomography (CT) scanning except in the setting of bullous disease1. Standard ventilation scintography has been used to diagnose and localize moderate sized peripheral BPF's, but its utility in the setting of a large BPF is questionable.
CASE PRESENTATION: A 58 y/o male was referred from an outlying facility for treatment of an empyema. He initially presented complaining of progressive dyspnea, cough with foul smelling sputum, weight loss, and fever. A CT scan revealed a large loculated pneumothorax with an air fluid level, a right middle lobe opacity, and mediastinal adenopathy. He had a history of chronic pancreatitis from ETOH abuse and a 30 pack year smoking history and had quit smoking about four months prior to admission. Physical examination revealed an ill appearing, alert, afebrile male in no distress. He had a pulse of 64 bpm; BP 132/61; R 18; T 98.4; SaO2 96% on room air; Ht 73”; Wt 69 Kg. Cardiopulmonary exam revealed diminished breath sounds throughout with tympanic percussion over the right chest. Abdominal exam revealed ascites without tenderness to palpation. Laboratory data which revealed an albumin of 2.3 and hemoglobin of 10.8. Sputum cultures were positive for alcaligenes sp. and he was continued on piperacillin/tazobactam. Bronchoscopy and video assisted thoracotomy with decortication was performed. Pathology revealed adenocarcinoma in the resected lung tissue. He was staged IIIB and his oncologist deferred chemotherapy due to his poor performance status. The patient had a persistent air leak post thoracotomy and returned to surgery for bronchoscopy and talc pleurodesis. A BPF was suspected and could not be localized. Pleurodesis was unsuccessful. He was not a candidate for pneumonectomy due to his performance status and residual pulmonary function. The fistula was not identified with CT scan. A ventilation lung scan was done with planar imaging which revealed a broad focus in the mid to apical portions of the right lung with homogenous distribution in the left. Single photon emission computed tomography (SPECT) imaging was then performed and by correlating the transverse and coronal images with CT demonstrated that the leak was in the superior and posterior portion of the right upper lobe, which was the area of the surgical clips from his previous thoracotomy. He underwent fiberoptic bronchoscopy with the placement of IBV® valves in the segments of the right upper lobe. The leak gradually decreased over the course of seven days and the patient discharged to home with a chest tube and a heimleich valve.
DISCUSSIONS: The case illustrates the difficulty that can occur in the management of a BPF. The patient had a BPF that was unable to be localized on CT or ventilation scintography. Using SPECT imaging the presence of BPF was confirmed and its precise location defined. This allowed for the directed placement of IBV for noninvasive management.
CONCLUSION: SPECT imaging can be a valuable tool in the diagnosis and localization of BPF in the non-operable patient who maybe a candidate for IBV.
DISCLOSURE: Michael Hull, None.