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A3177 - Chest Wall Abscess Ruptures into Post-Radiation Bulla Creating Multiple Bronchopleural Fistulas
Author Block: M. Hagner1, A. Aragaki Nakahodo2, S. Benzaquen2; 1Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH, United States, 2Interventional Pulmonology, University of Cincinnati, Cincinnati, OH, United States.
A bronchopleural fistula (BPF) is an abnormal connection between the airways proximal to the segmental bronchi and the pleural cavity. These communications arise from necrotizing infections, neoplasms, injuries involving the lung, or as a complication from procedures involving the chest wall. Here is a complex case describing a 61 year-old female with a past medical history of breast cancer status post radiation to the left chest wall (2003), chronic obstructive pulmonary disease (COPD), and chronic pulmonary histoplasmosis who was admitted to an outside hospital in December 2016 for a left spontaneous pneumothorax following a bout of coughing. She was found to have developed an acute BPF when a chest wall abscess ruptured an old post-radiation bulla in the left upper lung. This initial BPF was managed with surgery, however over time several chronic BPFs developed, involving an extensive air leak. She required five chest tubes placed on the left side with right main stem intubation for ventilation. Due to her extensive co-morbidities and critical status at this time, she was deemed a poor candidate for a second surgery. Interventional pulmonology performed a bronchoscopy where four endobronchial valves (EBVs) (superior and inferior segments of the lingula as well as apical-posterior and anterior segments of the left upper lobe) were placed with resolution of the air leak. Following the procedure, she was discharged to a skilled nursing facility (SNF) with only one chest tube and minimal ventilation settings. Repair of the air leak with the EBVs allowed for extubation and weaning to a trach collar. She remains ventilator dependent through her trach collar secondary to her extensive pulmonary co-morbidities, however her chronic pneumothoraces remain unchanged without any air leak. Repeat bronchoscopy allowed the removal of one EBV with the other three remaining stable at this time. Her clinical status is significantly improved, now being evaluated for possible lung transplantation. EBV placement offered a safe and effective alternative to treating these BPFs. The treatment of both acute and chronic BPFs are discussed and how their treatment is dictated by acuity. As many patients with a chronic BPF are poor candidates for a second operation due to co-morbidities or poor performance status, bronchoscopic treatments offer a safe and effective alternative. This case demonstrates how several BPFs were repaired in a critically ill patient using advanced bronchoscope techniques that served as the only option in an otherwise inoperable patient.