Bronchopleural Fistula With Persistent Air Leak Necessitating Endobronchial Valve Placement

First Author(s)

• 

  Zachary Estep, DO

  Resident Physician
  n/a
  Stamford, Connecticut, United States

  Disclosure information not submitted.

  Slides and Audio

Co-Author(s)

• FI

  Farwa Ilyas, MD

  MD
  Stamford Hospital, United States

  Disclosure information not submitted.
• RJ

  Raji Jasty, DO

  Resident Physician
  Stamford Hospital, United States

  Disclosure information not submitted.
• FH

  Frantz Hastrup, MD

  MD
  Stamford Hospital, United States

  Disclosure information not submitted.

Title: Bronchopleural Fistula With Persistent Air Leak Necessitating Endobronchial Valve Placement

Case Report Body:

Introduction:
Bronchopleural fistula (BPF) is communication between any area of the bronchial tree and pleural space, which commonly occurs following instrumental pulmonary injury and also in the setting of infection and malignancy. Persistent air leak (PAL) due to pulmonary damage is associated with increased morbidity and mortality, and longer length of hospital stay. Several invasive and non-invasive therapeutic options exist to treat PAL. We present a case of PAL due to BPF provoked by necrotizing pneumonia, necessitating endobronchial valve (EBV) placement.

Description:
A 61-year-old female with hypertension presented with deteriorating respiratory status after experiencing fevers, cough, malaise, shortness of breath, and labile blood pressures at home for six weeks. Vital signs were notable for hypotension, tachycardia, tachypnea, and hypoxia requiring 2L oxygen. Exam showed diaphoretic skin with diminished breath sounds and crackles bilaterally. Chest X-ray revealed peripheral infiltrates. She rapidly deteriorated requiring intubation and mechanical ventilation. Direct bronchoscopy revealed necrotizing pneumonia, further complicated by right sided hydrothorax, left sided tension pneumothorax, and pneumomediastinum resulting in multiple chest tubes, one of which had PAL. Computed tomography showed a right-sided bronchopleural fistula. Despite infection control and several weeks of observation and procedures, the PAL did not resolve. After identifying the affected lung segments via bronchoscopy, EBV was used under FDA expanded access authorization to successfully close off the leak and liberate the patient from the ventilator.

Discussion:
EBV are one-way valves initially developed for bronchoscopic lung volume reduction and approved in 2018 as treatment for severe emphysema. By occluding the affected lung segments, EBV prevent unnecessary ventilation to diseased lung tissue. In cases where BPF result in PAL, bronchoscopic balloon occlusion of the bronchial tree can aid in localization of the affected bronchial segments. EBV can then be deployed as an effective experimental treatment for PAL caused by BPF. EBV placement allows for precise control of PAL due to identification and localization of the affected lung segments contributing to the BPF and should be considered as an effective option for BPF with PAL.