Sandra Hui, MBBS, MMED
Associate consultant
n/a
singapore, Singapore
Disclosure information not submitted.
DUU WEN SEWA, MRCP
SENIOR CONSULTANT
SINGAPORE GENERAL HOSPITAL, United States
Disclosure information not submitted.
CHEE KIANG TAY, MRCP
CONSULTANT
SINGAPORE GENERAL HOSPITAL, United States
Disclosure information not submitted.
Title: The use of endobronchial spigots in extracorporeal membrane oxygenation weaning.
Introduction: Pneumocystis Jirovecii Pneumonia (PJP) predisposes patients to respiratory failure and pneumothoraces. Mechanical ventilation (MV) in a patient with Bronchopleural fistula (BPF) creates a Catch-22, whereby increased alveolar ventilation and reduced gas volume through BPF are simultaneously desired. Although reduced BPF leakage without compromising gas exchange could be achieved on extracorporeal membrane oxygenation (ECMO), weaning would prove problematic if the BPF fails to heal. We describe the use of endobronchial spigots in the weaning off ECMO in a patient with BPF.
Description: A 47-year-old Chinese male with retroviral disease presented with 2 days of fever and dyspnoea. His chest radiograph showed bilateral perihilar opacities and right upper zone hyperlucency. Bronchoalveolar lavage diagnosed PJP and he developed worsening hypoxemic respiratory failure requiring MV. He later developed a persistent right-sided pneumothorax with BPF despite intercostal drainage and eventually needed ECMO for refractory hypoxemia. Despite 2 weeks of ECMO support and lung rest, there was no improvement and endoscopic measures to treat the air leak were considered. Computed tomography scan of the chest confirmed the pneumothorax without any discernible BPF. The culprit bronchopulmonary segment was isolated by balloon occlusion via a Fogarty arterial-embolectomy catheter. After disconnecting the ventilator, the underwater seal was observed for air bubbles following each manually-bagged breath. As the patient's right upper lobe (RUL) demonstrated vertical bipartite anatomy, balloon occlusion (individual bronchopulmonary segments; apico-posterior trunk; entire lobe) was performed in that order. Three endobronchial Watanabe spigots (EWS) were deployed bronchoscopically to occlude the RUL. The patient underwent successful ECMO weaning after his right lung re-expanded.
Discussion: Pneumothoraxes and hypoxemia tend to co-exist in patients with PJP. Healing of the BPF can be hampered by the use of MV for life threatening hypoxemia. Bronchoscopic management can be considered in a patient who has failed conservative management. EWS have been used for treatment of persistent air leak with success rates of 40% to 85.7%. Here we describe the use of EWS for treatment of BPF to wean off ECMO.