INTRODUCTION: Spontaneous pneumothoraces can complicate COPD patients, often accompanied by a persistent air leak due to bronchopleural fistulas (BPF). The presence of BPF are rare but represents a challenging management. Bronchoscopic fistula closure has been reported as an acquiescent alternative to surgical interventions and its associated complications. In this case, we report our experience with closing a BPF by bronchoscopy using fibrin sealant in a patient with multiples comorbidities and high risk for surgical management.
CASE PRESENTATION: An 82 y/o male chronic smoker with Coronary Artery Disease and severe bullous emphysema, who for the last four months presented four episodes of recurrent left side spontaneous pneumothorax treated with chest thoracostomies. In his last admission he also suffered a subendocardial myocardial infarct, being discharged with ambulatory follow-up. One week later at the chest clinic, he was found again with a large left side pneumothorax. A new attempt with chest tube drainage was tried, but the patient persisted with an air leak due to a large BPF. Considering all the associated morbidities in this patient, we decided to attempt closure of the BPF with fibrin sealant. As described elsewhere, a Swan-Ganz (SG) catheter was introduced via bronchoscope. Upon distal balloon inflation of the SG catheter at the lung segments, wedging it in the apicoposterior segment of the left upper lobe ceased the bubbling in the water chamber seal, implying that this was the site where the fistula was present. Both subsegments were closed with Tisseel (fibrin and thrombin glue). 2 cc of fibrin sealant (Tisseel) were instilled through the SG cath distal tip. The balloon was left inflated for two minutes and then was deflated. The same procedure was performed on apical segment. Upon completion, bubbling in the water seal chamber stopped completely. Two days later chest tube was removed. Follow up chest radiograph showed resolution of pneumothorax. The patient was discharged home 4 days after the procedure. He is being follow in our clinics and no further clinical signs of pneumothorax recurrence have been reported since.
DISCUSSIONS: Spontaneous and recurrent pneumothoraces are serious, life threatening complications in COPD patients. The mortality range from 5 to 17% in the majority of series. BPF's are a rare complication in these patients but when present they are difficult to treat. If spontaneous sealing fails to occurs within the first 72 hours, surgical closure of the air leak together with pleurodesis or parietal pleurectomy may be indicated. Options for surgical repair include open-window drainage, thoracoplasty, omentopexy and intrathoracic muscle transposition. For patients with multiple comorbidities or that are too sick for surgical intervention there are reports of endoscopic closure of postoperative BPF with favorable results. Nonsurgical techniques for BPF closure include methacrylate, tissue glue, fibrin glue, gelfoam, tetracycline, autologous blood patch, lead plugs and balloon catheters.In this patient chest tube and talc pleurodesis therapy was ineffective. Due to the patient's multiple comorbidities both Cardiology and Thoracic surgery elected to manage the patient conservatively. Following case reports of successful closure of postresection BPF with minimal side effects with the use of fibrin sealant we decided for this method. We treated our patient through a flexible bronchoscope using a SG catheter in order to inflate its balloon and use the lumens. The fibrin glue was injected by high pressure followed immediately by thrombin through other lumen. A fibrin clot formed over the fistula, sealing the leak. It is believe that the fibrin glue is eventually reabsorbed, preventing tissue reaction to for foreign body.
CONCLUSION: Closure of BPF using fibrin glue is a safe and promising alternative to avoid surgical interventions and associated complications in patients with multiples comorbidities and high surgical risk.
DISCLOSURE: Brenda Loubriel, None.