SESSION TITLE: Bronchology/Interventional Procedures Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Transbronchial lung biopsy (TBBx) was once considered a high-risk procedure with pneumothorax, bleeding and death being the dreaded complications1. Over the years, improvements in the technique have not only increased diagnostic yield but also decreased the rate of complications. Here, we report hemopneumothorax as a rare complication of TBBx. To our knowledge, only two cases of hemopneumothorax have been reported; only one in the English language2.
CASE PRESENTATION: 82 year old male, former smoker with atrial fibrillation on coumadin and metastatic lung adenocarcinoma on ipilimumab and nivolumab presented with one week of cough and exertional dyspnea. CT chest showed bilateral lower lobe patchy consolidations and ground-glass opacities. INR was 2.57. Patient underwent diagnostic bronchoscopy with fluoroscopically-guided TBBx in the right lower lobe posterior segment after coagulopathy was corrected. No noted bleeding and no evidence of pneumothorax by fluoroscopy. In recovery, he reported severe right-sided chest pain not relieved by analgesics. Post-procedure chest X-ray showed only slight increase in right basilar atelectasis. Chest pain was persistent and hypoxia worsened two hours later. Repeat X-ray confirmed moderate right-sided pleural effusion with a component of pneumothorax. Pigtail catheter was placed and 1700ml of grossly bloody fluid drained revealing hematocrit of 29%. His hemoglobin dropped to 6.7 mg/dL by day 3 requiring transfusion. Drainage gradually ceased and chest tube was removed. Patient was discharged on day 6 after bronchoscopy.
DISCUSSION: Bleeding after TBBx usually occurs due to disruption of vessels within the lung parenchyma which often self-tamponades. Since our patient had a pleural disruption, it is likely that blood followed the path of least resistance and accumulated in the pleural cavity. If there is no observed bleeding during bronchoscopy this prompts the operator to consider an alternative etiology. Spontaneous hemothorax can occur after iatrogenic pneumothorax secondary to a torn vascular adhesion between the parietal and visceral pleurae leading to bleeding from a non-contractile vessel. Our patient had no known prior pleural disease.
CONCLUSIONS: We report this case to make clinicians aware of hemopneumothorax as a possible complication after TBBx.
Reference #1: Zavala DC. Pulmonary hemorrhage in fiberoptic transbronchial biopsy. Chest 1975. 70(5): 584-8.
Reference #2: Fujiwara M; Smith PR. Hemopneumothorax after Transbronchial Lung Biopsy. J Bronchology 2008. 15(1): 59-60.
DISCLOSURE: The following authors have nothing to disclose: Sakshi Sethi, Mohit Chawla
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