PURPOSE: Pneumocystis carinii pneumonia(PCP) in patients with acquired immunodeficiency syndrome(AIDS) may cause severe alveolar damage, and can result in pneumothoraces refractory to standard therapy. Pneumothorax occurs in 5%–9% of AIDS patients infected with PCP; of these, 50% will die during hospitalization. Patients who require mechanical ventilation for PCP-induced respiratory failure with concurrent pneumothorax, have a particularly high mortality rate of 92%. These patients often develop persistent bronchopleural fistulas which may be facilitated by positive pressure ventilation and corticosteroid therapy used for the treatment of PCP. Various modalities have been attempted to treat persistent PCP-induced bronchopleural fistulas. These include thoracotomy with direct closure (suture or staples), pleurodesis, or lobectomy; and placement of Heimlich flutter valves. No modality has shown benefit in patients on mechanical ventilation. One-way endobronchial valves have been shown in anecdotal reports to successfully treat persistent bronchopleural fistulas. Therefore, we proposed the placement of endobronchial valves for the treatment of PCP-induced bronchopleural fistulas in patients who are mechanically ventilated.
METHODS: Bronchial segments feeding the bronchopleural fistula were identified under direct bronchoscopic vision using the placement of a Fogarty catheter while monitoring for air leak in the chest tube chamber. Subsequently, one-way valves were sized and placed into these segments until the air leak was eradicated. Air leak, as judged by lost tidal volume on the ventilator, was recorded pre- and post-procedure.
RESULTS: Placement of one-way endobronchial valves successfully treated the bronchopleural fistula in this patient with PCP-induced respiratory failure; a 300 mL air leak was completely eradicated as a result of the valve placements. Despite successful treatment, the patient expired of refractory respiratory failure. Autopsy revealed cause of death to be due to refractory PCP; there was no evidence of post-obstructive pneumonia distal to the valves.
CONCLUSION: The placement of one-way endobronchial valves can ameliorate the effects of bronchopleural fistula in patients with PCP and respiratory failure.
CLINICAL IMPLICATIONS: Despite its apparent efficacy, further study needs to be undertaken to see if this treatment modality impacts mortality in this patient population.
DISCLOSURE: Sonali Sethi, No Financial Disclosure Information; No Product/Research Disclosure Information