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Management of Alveolar-Pleural FistulaEndobronchial Application of Synthetic Hydrogel: A Complex Medical and Surgical Problem FREE TO VIEW

Ali I. Musani, MD, FCCP; Hervé Dutau, MD
Author and Funding Information

From the Division of Pulmonary, Critical Care and Sleep Medicine (Dr Musani), National Jewish Health; and the Thoracic Endoscopy Unit (Dr Dutau), Thoracic Oncology, Pleural Diseases and Interventional Pulmonology Department, North University Hospital.

CORRESPONDENCE TO: Ali I. Musani, MD, FCCP, National Jewish National Jewish Health, J-225, Molly Blank, 1400 Jackson St, Denver, CO 80206; e-mail: MusaniA@NJHealth.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following conflicts: Dr Musani is the site principal investigator for the Spiration EBV humanitarian use study at National Jewish Health, Denver Colorado. Dr Dutau reports that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(3):590-592. doi:10.1378/chest.14-2202
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Alveolar-pleural fistula (APF) and bronchopleural fistula (BPF) are uncommon yet frustrating medical and surgical problems with high morbidity and mortality. They may originate spontaneously or be encountered after bronchoscopy or thoracic surgery. However, they are almost always caused by an underlying pulmonary pathology, which seems to be the most important prognostic factor.

Reparative surgeries are never a desired first therapeutic option for APF or BPF. Pleurodesis with chemicals such as talc and thoracic surgery have had high failure rates.1 Unfortunately, pleural and bronchscopic interventions have had limited success as well. Bronchoscopic options for APF and BPF have been marred by technical problems, although their conceptual foundation is appealing. Airway occluding devices and agents have been used for decades. These modalities include endobronchial Watanabe spigots (Novatech), gelfoams, endobronchial valves, and synthetic hydrogel.

A Watanabe spigot functions by blocking the airway leading to the fistula. The spigot looks somewhat like a wine bottle cork. It is grasped with forceps passed through the working channel of the bronchoscope and pushed out into the target airway. Although spigots are perhaps the most simplistic of bronchoscopic approaches, their migration was a significant problem in several studies.2

Prior to application of a spigot or any other endobronchial modality, the fistula is localized using information about the surgical site or by chest CT scan examination. The location is confirmed by occluding the airway with an inflated Fogarty balloon catheter or another commercially available sizing balloon. When the balloon occludes the airway leading to the fistula, bubbling stops in the water seal chamber of the chest drainage system. Balloons also provide an estimate of the size of the device needed to block the airway orifice.

Endobronchial valves are perhaps one of the most established and successful modalities for treating APF and BPF. Currently, two different endobronchial valves are available: the Zephyr valve (Pulmonx) and the Spiration IBV Valve System (Spiration, Inc). The IBV is the only valve with US Food and Drug Administration approval (humanitarian) in the United States. The experience with its humanitarian use and success in treating postsurgical BPF3,4 led to Food and Drug Administration approval for BPF. The IBV is currently being evaluated in clinical trials for use in bronchoscopic lung volume reduction. The IBV is a one-way valve that looks somewhat like a miniature umbrella and comes in multiple sizes. The valve is loaded into a catheter passed through the working channel of the bronchoscope and pushed into the target airway to occlude it. The valve blocks the flow of air into the affected lung segment, promoting healing of the fistula. Some of the key features of the IBV are its reversibility and its shape, which allows secretions and trapped air to exit the airway while blocking the inward flow of air into the damaged lung segment. However, collateral ventilation is not addressed by endobronchial valves, which may account for the majority of valve treatment failures.

In this issue of CHEST, Mehta et al5 (see page 695) describe their retrospective experience with > 20 cases of APF treated with a novel modality, a synthetic hydrogel (CoSeal; Baxter Healthcare Corp). CoSeal is composed of two synthetic polyethylene glycols (PEGs). The two PEG solutions are applied endobronchially via a flexible polyurethane catheter (Duplocath; Baxter Healthcare Corp) deployed through the working channel of the bronchoscope. When the two compounds mix in the airway, they polymerize, forming a sealant plug. Within a few minutes, the sealant congeals in the airway to occlude the predetermined target airway leading to the fistula. The plug is gradually resorbed over the next 2 weeks, reducing the risk of complications such as postobstructive pneumonia and atelectasis. In their study, Mehta et al5 were able to successfully stop air leaks in 85% of the patients within 2 ± 1 days.

Some of the unique properties of CoSeal include “auto-reversibility” (the compound resorbs in 2 weeks) and ease of use. It is also possible that the initial liquid nature of the compound may better occlude collateral ventilation channels, thus promoting healing of the fistula. Larger prospective trials of CoSeal are needed to answer questions about its effectiveness in occluding large fistulas involving multiple lung segments or lobes and its short-term reversibility in the event of therapeutic failure or worsening respiratory status.

The current bronchoscopic management of BPFs varies based on the severity of the BPF and personal experience with available modalities. For small BPF, gel foams, spigots, CoSeal, and valves can all work effectively if chosen appropriately from a technical standpoint. For instance, spigots tend to dislodge and migrate out of the location where they were originally placed compared with valves. Similarly, in areas with a potentially high likelihood of collateral channels, modalities such as CoSeal may work better compared with valves. For large fistulas involving the lobar bronchi or mainstem bronchi seen in patients with posttransplant dehiscence or postpneumonectomy or postlobectomy dehiscence, silicone stents or fully covered metallic stents placed temporarily may work better than other modalities. Silicone stents are generally preferred because they are easy to remove and can be made to order, such as an inverted “Y” stent with one of the main limbs cut just below the crina and sealed at the end to prevent any airflow through that particular mainstem airway. Similarly, a cone-shaped (tapered) custom-made stent can be placed from the trachea into one of the mainstem bronchi, bypassing the effected mainstem bronchi with the defect.6,7

References

Puskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for. J Thorac Cardiovasc Surg. 1995;109(5):989-995. [CrossRef] [PubMed]
 
Watanabe Y, Matsuo K, Tamaoki A, Komoto R, Hiraki S. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchology. 2003;10(4):264-267. [CrossRef]
 
Toma TP, Kon OM, Oldfield W, et al. Reduction of persistent air leak with endoscopic valve implants. Thorax. 2007;62(9):830-833. [CrossRef] [PubMed]
 
Gillespie CT, Sterman DH, Cerfolio RJ, et al. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011;91(1):270-273. [CrossRef] [PubMed]
 
Mehta HJ, Malhotra P, Begnaud A, Penley AM, Jantz MA. Treatment of alveolar-pleural fistula with endobronchial application of synthetic hydrogel. Chest. 2015;147(3):695-699.
 
Dutau H, Breen DP, Gomez C, Thomas PA, Vergnon JM. The integrated place of tracheobronchial stents in the multidisciplinary management of large post-pneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent. Eur J Cardiothorac Surg. 2011;39(2):185-189. [CrossRef] [PubMed]
 
Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128(6):3955-3965. [CrossRef] [PubMed]
 

Figures

Tables

References

Puskas JD, Mathisen DJ, Grillo HC, Wain JC, Wright CD, Moncure AC. Treatment strategies for. J Thorac Cardiovasc Surg. 1995;109(5):989-995. [CrossRef] [PubMed]
 
Watanabe Y, Matsuo K, Tamaoki A, Komoto R, Hiraki S. Bronchial occlusion with endobronchial Watanabe spigot. J Bronchology. 2003;10(4):264-267. [CrossRef]
 
Toma TP, Kon OM, Oldfield W, et al. Reduction of persistent air leak with endoscopic valve implants. Thorax. 2007;62(9):830-833. [CrossRef] [PubMed]
 
Gillespie CT, Sterman DH, Cerfolio RJ, et al. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011;91(1):270-273. [CrossRef] [PubMed]
 
Mehta HJ, Malhotra P, Begnaud A, Penley AM, Jantz MA. Treatment of alveolar-pleural fistula with endobronchial application of synthetic hydrogel. Chest. 2015;147(3):695-699.
 
Dutau H, Breen DP, Gomez C, Thomas PA, Vergnon JM. The integrated place of tracheobronchial stents in the multidisciplinary management of large post-pneumonectomy fistulas: our experience using a novel customised conical self-expandable metallic stent. Eur J Cardiothorac Surg. 2011;39(2):185-189. [CrossRef] [PubMed]
 
Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128(6):3955-3965. [CrossRef] [PubMed]
 
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