Procedures: Fellow Case Report Poster - Procedures |

Intraoperative Flow Volume Data From Mechanical Ventilator as a Surrogate for Successful Closure of Refractory Bronchocutaneous Fistula With Intrabronchial Valve Placement FREE TO VIEW

Deepankar Sharma, MD; Christina Bellinger, MD; Adrian Lata, MD; Arjun Chatterjee, MD
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Wake Forest University School of Medicine, Winston Salem, NC

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):986A. doi:10.1016/j.chest.2016.08.1092
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SESSION TITLE: Fellow Case Report Poster - Procedures

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Bronchopleural fistula (BPF) refers to a leakage of inspired air from airways into pleural space for more than 24 hours. Surgical procedures remain the leading cause of a BPF followed by ruptured bulla(e), necrotizing infections, radiation therapy, ARDS and iatrogenic1. Traditionally, BPF have been managed with thoracostomy, pleurodesis and surgical repair. Recently, endobronchial techniques have been used with success including fibrin glue, Amplatzer device, tracheobronchial stents and intrabronchial valves (IBV). We describe a case of refractory BPF treated with IBV placed using intraoperative mechanical ventilator flow dynamics.

CASE PRESENTATION: A 66 y/o man with h/o right middle and lower lobectomy for stage 1 lung cancer was referred to our clinic for persistent bronchopleuro-cutaneous fistula. He underwent bi-lobectomy in 2010 and developed BPF in 2014 after necrotizing pneumonia. He underwent a right upper lobe flap repair and decortication in 2015 followed by open abscess drainage. He had a tube thoracostomy for a few months before he developed cutaneous fistula with a tract that failed to heal despite daily closure dressings. We placed 4 IBV (Spiration) using a flexible bronchoscope under general anesthesia while using his exhaled tidal volume from the ventilator as an indicator of successful occlusion. At 10 weeks follow up, the cutaneous fistula had completely healed with no air leak and patient reported significant improvement in shortness of breath.

DISCUSSION: BPF represent a severe complication of lobectomy/pneumonectomy with a reported incidence from 1.5 to 28%2. IBVs have shown to decrease oxygen requirements, duration of mechanical ventilation, thoracostomy tube time and improve pulmonary function3. Occluding the airway with a balloon while monitoring air leak from the thoracostomy tube is the usual method of choosing optimal site to deploy IBVs. We used the increment in his exhaled tidal volume as recorded by the ventilator to choose the appropriate segments to occlude. The air leak was adequately sealed leading to resolution of the fistula.

CONCLUSIONS: Using exhaled tidal volumes from mechanical ventilator intraoperatively is an effective method to determine optimal site for IBV deployment.

Reference #1: Bronchopleural fistula: An update for intensivists J Crit Care. 2010 Mar;25(1):47-55

Reference #2: Incidence and Management of Post-Lobectomy and Pneumonectomy Bronchopleural Fistula Lung. 2016 Apr;194(2):299-305

Reference #3: Endobronchial Valves in the Treatment of Persistent Air Leaks Ann Thorac Surg. 2015 Nov;100(5):1780-5

DISCLOSURE: The following authors have nothing to disclose: Deepankar Sharma, Christina Bellinger, Adrian Lata, Arjun Chatterjee

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