Journal of Bronchology & Interventional Pulmonology:
Moody, Gina N. DO; Zeno, Brian R. MD, FCCP
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Riverside Methodist Hospital, Columbus, OH
Reprints: Gina N. Moody, DO, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Riverside Methodist Hospital, 3535 Olentangy River Road, Columbus, OH 43214 (e-mail: email@example.com).
Received for publication January 11, 2010; accepted January 25, 2009
There is no conflict of interest.
Bronchopleural fistula (BPF) is a feared complication in the setting of pneumonectomy, lobectomy, and pulmonary infection. The development of BPFs significantly increases morbidity and mortality, and their treatment is complicated, multifaceted, and variable in success. Recently, the use of fibrin glues, acrylic glues, and endobronchial valves through bronchoscopy has allowed for minimally invasive treatment, sparing the patient surgical intervention. Results in the literature for these modalities have been mostly positive in a variety of clinical scenarios. Regardless of the therapeutic interventions used, proper diagnosis and localization of these fistulas is essential. These modalities have traditionally included installation of methylene blue in the pleural space, balloon occlusion, and ventilation scintigraphy. Here, we report the successful localization and treatment of a BPF through the use of localized bronchoscopic capnography in a 30-year-old woman with a complicated BPF. Initial attempts to localize the fistula with Fogarty catheter balloon occlusion were unsuccessful, as multiple segments were involved. Ultimately, with a capnographic catheter, the precise segments could be identified and subsequently occluded with acrylic glue. Air leak and pneumothorax resolved, chest tubes were removed without complication, and the patient was discharged 2 days after the procedure.
Bronchopleural fistula (BPF) is a feared complication in the setting of pneumonectomy, lobectomy, and pulmonary infection. Multiple bronchoscopic techniques have emerged for minimally invasive treatment of BPFs. Regardless of the therapeutic interventions, proper diagnosis and localization of these fistulas is essential. Capnography offers precise localization in complicated BPFs in which multiple subsegments are involved.
A 30-year-old woman with a medical history significant for chronic back pain presented with complaints of fever and cough of several days' duration. After a heavy coughing spell, the patient had a syncopal event that ultimately brought her to medical attention. Initial work-up showed leukocytosis with a white blood cell count of 22,000 and a temperature of 99.7°F. Chest radiographs showed dense right upper lobe and right lower lobe infiltrates. Chest computed tomography was significant for large consolidation in the right upper lobe and a large right-sided hydropneumothorax (Fig. 1). Broad-spectrum antibiotics were initiated. A thoracostomy tube was placed but the right upper lobe failed to expand. Thoracic surgeons subsequently performed a muscle-sparing thoracotomy with right lung decortication and biopsy. Two additional chest tubes were placed during surgery. Postoperatively, the chest tubes continued to show a significant air leak throughout the respiratory cycle. Over the next 2 weeks, 2 of the chest tubes were removed, but a large air leak remained in the existing chest tube and evidence of this hydropneumothorax was observed on serial chest films.
Our pulmonary service was consulted for management of this persistent BPF. Given the lack of response to surgical treatment, the patient was considered for minimally invasive closure through bronchoscopy. Before this could be accomplished, precise localization of the fistula was indicated. An initial bronchoscopy with balloon occlusion of pulmonary subsegments was attempted with a Fogarty catheter but was unable to isolate the source of the fistula, raising the concern for the involvement of multiple segments. We felt that identification of the fistula with capnography could be highly useful in this clinical situation.
The patient was informed of the risks and benefits of the procedure and she was given conscious sedation with Versed and fentanyl. The bronchoscope was introduced through the mouth and advanced to the tracheobronchial tree. The chest tube was disconnected from the water seal, allowing for atmospheric communication. A capnographic catheter was passed through the working channel of the bronchoscope and subsequently placed in each segment and subsegment of the right lung (Fig. 2). The CO2 curve remained stable until placement in the anterior segment of the right upper lobe. When placed here, there was cessation of the CO2 return on the monitor, suggesting this to be the involved segment. Two days later, the patient returned to the bronchoscopy suite. Anesthesia was performed in the traditional manner and the chest tube was disconnected from the water seal. Acrylic glue was inserted into the anterior segment of the right upper lobe without incident and this seemed to successfully occlude the right upper lobe (Fig. 3). The chest tube was reconnected and a significant decrease in the air leak was noted. This air leak resolved the next day. Two days later, the chest tube was clamped and follow-up chest x-ray failed to show the reappearance of any pneumothorax. The patient was successfully discharged from the hospital after an almost 2-month hospital stay.
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BPF represents an abnormal communication between the pleural space and bronchial tree and significantly increases a patient's morbidity, mortality, and length of hospital stay. Earlier studies show mortality rates to be between 29% and 70%.1 This illustrates the need for effective treatment alternatives. Historically, conservative treatment has been difficult and results variable. Surgical intervention has long been the standard of care for patients in whom there are no contraindications,2 although advances in therapeutic bronchoscopy have obviated the need for this in many patients.
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In recent years, conservative closure techniques with glue (both fibrin and acrylic)3 and endobronchial valves4 have shown promise in the conservative management of patients with BPFs. These methods have spared some patients more invasive surgical procedures, but the results with these modalities are mixed. This may be due, in part, to difficulty localizing the exact segment or subsegment involved. Balloon occlusion with a Fogarty catheter has frequently been used to locate the site of the fistula.5 Although balloon occlusion can certainly help in identifying the affected segment or subsegment by occluding the fistulous communication, it lacks the precision offered by capnography. If multiple segments are involved, placing the balloon in one segment will not occlude the abnormal communication entirely, and an air leak will persist. In contrast, capnography allows for precise identification of each involved subsegment. The lack of CO2 return will be evident on the monitor when the catheter is placed in each involved segment or subsegment.
Bhattachayya et al report the use of capnography in 7 patients at their institute.6 In each patient, excellent localization and subsequent closure are described. In contrast to our patient, all of their patients were elderly and had multiple comorbidities that made surgery contraindicated. This case represents a surgical treatment failure that was effectively diagnosed and treated bronchoscopically. This is compelling in that the standard of care for definitive management of these patients may be shifting from one of surgical management to that of minimally invasive treatment through bronchoscopy.
On the basis of our results and those of ongoing studies involving closure techniques, it seems feasible that with more precise localization, conservative management of BPFs could become the mainstay of treatment and not just an option of last resort. Used as an adjuvant to closure devices such as endobronchial valves or glue, capnography detection of BPFs may not only provide a more comfortable, less invasive means of treatment but may also help reduce the length of hospital stay, morbidity, and mortality of these challenging patients.
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