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A6468 - Endobronchial Blockade for Lung Isolation in the Setting of Unilateral Necrotizing Pneumonia as a Bridge to Pneumonectomy
Author Block: C. Ellison1, B. Morris2, P. Miller2, V. Vachharajani2, R. Jain2, D. LoVerde3; 1Pulmonary, Critical Care, Allergy and Immunology, Wake Forest Baptist Medical Center, Winston-Salem, NC, United States, 2Anesthesiology, Wake Forest Baptist Medical Center, Winston Salem, NC, United States, 3Pulmonary, Critical Care, Allergy and Immunology, Wake Forest Baptist Medical Center, Winston Salem, NC, United States.
Introduction: Management of necrotizing pneumonia typically requires a prolonged course of antibiotics and occasionally surgical resection in refractory cases.
Case: 52 year old white male was transferred to the ICU at Wake Forest Baptist Medical Center (WFBMC). He presented to an outside hospital (OSH) with two weeks of flu-like symptoms, shortness of breath and hemoptysis. He developed progressive hypoxemic respiratory failure with septic shock requiring intubation and vasopressors. Computerized Tomography (CT) chest demonstrated necrotizing pneumonia/pulmonary abscess with cavitation involving the right upper lobe. Respiratory culture was positive for Methicillin Resistant Staphylococcus Aureus (MRSA). Vancomycin, piperacillin-tazobactam and azithromycin were administered and he was transferred to WFBMC, where imaging demonstrated bilateral infiltrates consistent with Acute Respiratory Distress Syndrome (ARDS) and progression of right abscess. He developed MRSA bacteremia, right-sided empyema, spontaneous pneumothorax with bronchopleural fistula requiring chest tube placement. Respiratory, pleural and blood cultures were positive for MRSA and antibiotics changed to Vancomycin and Clindamycin. Extracorporeal membrane oxygenation (ECM0) was initiated after blood cultures were clear for 48 hours. Insertion of endobronchial blocker in the right mainstem was performed for lung isolation and to minimize contralateral contamination. Bronchoscopy was performed for pulmonary toilet twice daily. After 48 hours the right mainstem bronchus demonstrated visible evidence of pressure injury at the site of the endobronchial balloon. Bronchial blocker was discontinued and left mainstem bronchus was selectively intubated. Bronchoalveolar lavage cultures of the right lung were persistently positive despite appropriate antibiotics at appropriate trough levels. On day 10, he began to decompensate and required increasing vasopressor support. Intrapleural thrombolytics were administered to facilitate chest tube drainage, which produced lung re-expansion but complicated by pulmonary hemorrhage. His clinical condition continued to worsen, the contralateral lung demonstrated pulmonary opacities and grew MRSA on bronchoalveolar lavage. Given his clinical instability and contralateral lung contamination surgery was no longer possible. His family elected to withdraw treatment.
Discussion:Our case demonstrates an unconventional management strategy of intractable pulmonary abscess. We used lung isolation to prevent contralateral contamination as a bridge to right sided pneumonectomy. This technique was unsuccessful, possibly due to late initiation of the intervention and difficulty maintaining endobronchial balloon placement. Evidence for utilizing this intervention is exclusively case reports and no strong data exists. If this intervention is to be utilized we recommend early initiation with a limited duration of time, with monitoring for evidence of compression injury and tissue ischemia at the site of the balloon.