SESSION TITLE: Pleural Disease Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Tube thoracostomy is a commonly performed procedure for the chest physician. We report a case of bronchocutaneous fistula (BCF) that developed as a result of tube thoracostomy to heighten awareness of this rare complication.
CASE PRESENTATION: A 59 year-old male patient with a past history of severe chronic obstructive pulmonary disease requiring long term oxygen therapy was admitted for sudden onset of shortness of breath. Serial chest radiographs (CXR) showed a lucent area in the lateral left hemithorax, which was suspected to be a bulla. Computed tomography (CT) confirmed a pneumothorax and a 20Fr chest tube was inserted and kept in place for 7 days. It was removed when there was no bubbling in the underwater seal and after CXR confirmation of full lung reexpansion. One week later, the patient developed dyspnea, agitation and decompensated type 2 respiratory failure. CT thorax at that time showed recurrence of left pneumothorax. Chest tube was inserted with difficulty as the patient was agitated. Serial CXRs showed persistence of the pneumothorax with continuous bubbling despite applying suction. There was also increasing subcutaneous emphysema. CT thorax was repeated which showed the tip of the chest tube being wedged against collapsed lung tissue with the entire course of the chest tube being embedded within lung parenchyma. In view of its suboptimal position, the chest tube was removed and a new one inserted. CXR showed full lung reexpansion afterwards. However, the 2nd chest tube slipped out before pleurodesis could be done for recurrent secondary spontaneous pneumothorax. Repeat CT showed resolution of the pneumothorax with a bronchocutaneous fistula along the course of the 1st chest tube. The patient was transferred to the cardiothoracic surgical unit where he was observed for persistent subcutaneous emphysema and possibility of pneumothorax recurrence. The subcutaneous emphysema resolved and he was discharged. Six months later, he is well and without further pneumothorax recurrence.
DISCUSSION: The causes of BCFs are: postoperative complications (pneumonectomy or lung resection); chronic inflammation or infection; chemotherapy and internal or external chest trauma (barotrauma, tube thoracostomy) . During tube thoracostomy, accidental lung perforation creates a fistulous tract from the skin to the lung parenchyma, thus creating a BCF. The procedure was not smooth in our patient as he was agitated, likely related to his hypercapnea. A diagnosis of BCF requires a high index of suspicion. One clue to diagnosis is the bronchial leak squeak sign, which is a high pitched squeak heard over the hemithorax containing the fistula during a Valsalva maneuver . On CXR, the fistula is almost never seen. Instead, clues to its presence are an air-fluid level in the pleural space (hydropneumothorax) . Diagnosis is by CT to confirm its presence and to delineate its course. Most BCFs due to trauma can often be managed by tube thoracostomy and usually resolve spontaneously . Surgery is indicated when there is injury to the trachea, pulmonary vessels or major bronchi .
CONCLUSIONS: CXR features of BCF are subtle. In a patient with tube thoracostomy followed by subcutaneous emphysema, a CT should be done to look for possible BCF.
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DISCLOSURE: The following authors have nothing to disclose: YL Erica Leung, Samuel Lee
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