SESSION TITLE: Bronchology Cases I
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 27, 2013 at 01:15 PM - 02:45 PM
INTRODUCTION: Endobronchial Ultrasound (EBUS) was developed to help visualize structures beyond the airway wall. This includes real-time ultrasound guidance during transbronchial needle aspiration (TBNA). This improves the diagnostic yield and sensitivity as compared to conventional TBNA. While typically employed to sample mediastinal lymph nodes and masses, it has also been used to drain mediastinal cysts, sample tumors within the pulmonary vessels and detect pulmonary emboli. We present a unique case of using EBUS to drain a parabronchial loculated pleural effusion which led to distal tracheal and bronchial compression. This collection could not be accessed safely by routine ultrasound-guided thoracentesis.
CASE PRESENTATION: A 67-year-old female was referred to the Pulmonary service for progressive dyspnea. She had a history of Stage IV ovarian cancer and previously underwent an extensive debulking surgery followed by multiple lines of chemotherapy. Despite this, she developed progression of her disease with metastases to her lungs and pleura. For malignant pleural effusion, she had a right indwelling pleural catheter placed with daily drainage of approximately 200cc. However, she developed progressive respiratory insufficiency. A CT scan revealed a multiloculated right pleural effusion including a large subcarinal fluid collection leading to obstruction of the distal trachea and multiple pleural based metastases leading to extrinsic compression of the bronchus intermedius . Flexible bronchoscopy confirmed these findings. Convex EBUS was utilized to localize the subcarinal fluid collection via the right mainstem bronchus and assist with the fluid drainage; 135cc was successfully drained with subsequent improvement in distal tracheal caliber. A self-expanding metallic stent was then placed in the bronchus intermedius. The patient had significant improvement in her dyspnea following the procedure.
DISCUSSION: EBUS-TBNA is valuable as a minimally-invasive and low-risk procedure for the diagnosis of mediastinal and hilar lesions. It is increasingly being used for novel purposes, such as drainage of mediastinal cysts, sampling of tumors invading pulmonary vessels and detecting pulmonary emboli.
CONCLUSIONS: We propose that EBUS-guided thoracentesis can be successfully employed for the drainage of loculated pleural fluid that might not otherwise be accessible by conventional methods of drainage. Such drainage can be safely performed for diagnostic and therapeutic intent.
Reference #1: Nakajima T, Kazuhiro Y, Kiyosh Si, Fujisawa T. Endobronchial ultrasound-guided transbronchial needle aspiration for the treatment of central airway stenosis caused by a mediastinal cyst. Eur J Cardiothorac Surg 2007;32:538-40.
Reference #2: Swartz MA, Gillespie, CT. Pulmonary Emboli Detected by Endobronchial Ultrasound. Am J Respir Crit Care Med 2011;183:1569.
Reference #3: MacEachern P, Dang B, Stather D, Tremblay A. Tumor Invasion Into Pulmonary Vessels Viewed by Endobronchial Ultrasound. J Bronchol 2008;15:206-7.
DISCLOSURE: The following authors have nothing to disclose: Preethi Rajan, Satish Kalanjeri, Mohit Chawla
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