SESSION TITLE: Interventional Pulmonary Cases
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM
INTRODUCTION: We describe a patient with severe pneumonia complicated by acute respiratory distress syndrome (ARDS), lung abscess and bilateral pneumothoraces with pneumomediastinum secondary to a bronchopleural fistula. The bronchopleural fistula was managed by bronchoscopic insertion of endobronchial valves to collapse the left lower lobe.
CASE PRESENTATION: A 35 year old alcoholic man was admitted to intensive care with severe sepsis, bilateral pneumonia and alcoholic ketoacidosis. He developed ARDS requiring mechanical ventilation and subsequently extracorporeal membrane oxygenation (ECMO) for 10 days and tracheostomy formation. Following ECMO wean, the patient developed a left intra-parenchymal lung abscess and possible empyema for which an intercostal chest catheter was inserted. He then developed pneumomediastinum, pneumoretroperitoneum and pneumothorax secondary to a bronchopleural fistula (see Figure 1). This compromised effective mechanical ventilation with the patient requiring airway pressure release ventilation (APRV) on FiO2 0.8 and peak pressures 27-33 cm H2O, with a PaO2 of 60 mm Hg and PaCO2 of 64 mm Hg. A temporary bronchial blocker was inserted to collapse the left lower lobe. Definitive therapy with bronchoscopic insertion of 7 endobronchial valves (PulmonX Inc Zephyr® valves) was achieved. The patient required 3 months in intensive care and 4 months in hospital. He was transferred to a rehabilitation unit before return to independent living. The endobronchial valves were removed 6 months after insertion with good clinical and radiological outcomes.
DISCUSSION: We describe the successful use of endobronchial valve insertion in a septic patient with ARDS and profound hypoxaemia on mechanical ventilation with a bronchopleural fistula. Radiological differentiation between intra-parenchymal abscess and empyema can be difficult but is important to guide appropriate therapy.
CONCLUSIONS: Bronchoscopic insertion of endobronchial valves to treat bronchopleural fistulae has been described in a variety of settings.1 This case illustrates its potential usage in a critically unwell and hypoxaemic patient who would not have tolerated surgical intervention.
Reference #1: Travaline et al (2009). Treatment of persistent pulmonary air leaks using endobronchial valves. Chest; 136: 355-360.
DISCLOSURE: The following authors have nothing to disclose: Kuan Pin Lim, Melanie Lavender, Michael Musk, Jeremy Wrobel
Endobronchial valve (Zephyr, PulmonX) insertion for bronchopleural fistula.