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Disorders of the Pleura |

Successful Closure of a Bronchopleural Fistula by Intrapleural Administration of Fibrin Sealant: A Case Report

Pranabh Shrestha, MD; Javier Dieguez, MD; Enis Alberaqdar, MD; Sami Abdul Jawad, MD; Srijana Rai, MD; Marc Adelman, MD
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St. Michael's Medical Center, Newark, NJ


Chest. 2013;144(4_MeetingAbstracts):487A. doi:10.1378/chest.1685553
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Abstract

SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree [1]. Common causes include complications of pulmonary resection, persistent spontaneous pneumothorax, chemotherapy/radiotherapy for lung cancer, tuberculosis, and empyema [1,2]. We present a case in which a BPF complicating an empyema was successfully managed by infusing fibrin sealant through a chest tube.

CASE PRESENTATION: A 53-year-old male presented with productive cough for 1 week. On examination, he had a pulse of 105bpm and oxygen saturation of 91% at room air. Chest auscultation revealed decreased breath sounds with decreased vocal resonance on the left infrascapular region. Chest CT showed a large loculated left pleural effusion measuring 9cmX12cm surrounded by a thickened pleural wall. Because of increasing respiratory distress, trachea was intubated and broad-spectrum antibiotics administered. A CT-guided thoracostomy was performed leading to evacuation of a brownish and extremely foul-smelling fluid. Pleural fluid culture grew Streptococcus intermedius. The patient made a good recovery on ampicillin-sulbactam and was successfully extubated on day 10. The patient, however, continued to have a persistent air leak through the chest tube, leading to a diagnosis of BPF. After initial attempt at bronchoscopic localization of the BPF failed, we decided to attempt the closure of the fistula by administering fibrin glue directly through the chest tube. Two 10ml Tisseel™ prefilled syringes were obtained. The two components in the syringe were poured into two sterile cups, with one containing 10 ml of the sealer protein solution and the other containing 10 ml of the thrombin solution. The solutions were each diluted with 30 ml of normal saline. The first solution was then infused into the pleural space through the chest tube quickly followed by the second solution. The chest tube was clamped for 15 minutes after which no air leak was seen. The chest tube was removed the following day and the patient was discharged home. On subsequent visits, serial radiographs were obtained which did not show any pneumothorax.

DISCUSSION: A bronchopleural fistula is a rare albeit challenging problem. We presented a case where we were able to successfully manage a BPF via an intrapleural infusion of fibrin sealant. We based our management on the methods employed by Kinoshita et al [3].

CONCLUSIONS: Use of a fibrin sealant infused directly via a chest tube was effective in sealing a BPF secondary to an empyema.

Reference #1: Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest 2005; 128:3955-65

Reference #2: Hankins JR, Miller JE, Attar S, et al. Bronchopleural fistula, thirteen-year experience with 77 cases. J Thorac Cardiovasc Surg 1978; 76:755-62

Reference #3: Kinoshita T, Miyoshi S, Katoh M, et al. Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax. Chest 2000; 117:790-95

DISCLOSURE: The following authors have nothing to disclose: Pranabh Shrestha, Javier Dieguez, Enis Alberaqdar, Sami Abdul Jawad, Srijana Rai, Marc Adelman

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