Membrana de oxigenación extracorpórea venovenosa como puente a la reparación de una fístula bronquial traumática / Venovenous extracorporeal membrane oxygenation as a bridge to traumatic bronchial fistula closure

Las lesiones traqueobronquiales traumáticas ocurren en el 1% de los pacientes con traumatismo torácico, y la mayoría de ellos fallecen en el lugar del trauma. En este caso clínico presentamos a una paciente de 26 años de edad, ingresada en UCI debido a un traumatismo torácico cerrado causando hipoxemia y acidosis grave, decidiéndose implantar la membrana de oxigenación extracorpórea percutánea venovenosa. El uso de membrana de oxigenación extracorpórea percutánea venovenosa, iniciado con un objetivo de anticoagulación más bajo, permitió el diagnóstico y tratamiento de una fístula broncopleural en condiciones de estabilidad respiratoria y hemodinámica sin complicaciones hemorrágicas, obteniendo una asistencia rápida y adecuada para la supervivencia de la paciente

Traumatic tracheobronchial injuries occur in 1% of patients with thoracic trauma, most of them dying at the site of the trauma. In this case report, we present a 26-year-old female patient admitted to the ICU due to a blunt chest trauma causing life threatening hypoxaemia and acidosis; deciding to implant percutaneous venovenous extracorporeal membrane oxygenation. The use of percutaneous venovenous extracorporeal membrane oxygenation, implemented with a lower anticoagulation target, allowed the diagnosis and treatment of a bronchopleural fistula under conditions of respiratory and hemodynamic stability without haemorrhagic complications, obtaining a fast and adequate assistance achieving the survival of the patient

Venovenous extracorporeal membrane oxygenation as a bridge to traumatic bronchial fistula closure. / Membrana de oxigenación extracorpórea venovenosa como puente a la reparación de una fístula bronquial traumática.

Traumatic tracheobronchial injuries occur in 1% of patients with thoracic trauma, most of them dying at the site of the trauma. In this case report, we present a 26-year-old female patient admitted to the ICU due to a blunt chest trauma causing life threatening hypoxaemia and acidosis; deciding to implant percutaneous venovenous extracorporeal membrane oxygenation. The use of percutaneous venovenous extracorporeal membrane oxygenation, implemented with a lower anticoagulation target, allowed the diagnosis and treatment of a bronchopleural fistula under conditions of respiratory and hemodynamic stability without haemorrhagic complications, obtaining a fast and adequate assistance achieving the survival of the patient.

Hemodynamic, ventilatory and gasometric evaluation of an experimental bronchopleural fistula.

PURPOSE: To investigate the hemodynamic and ventilatory changes associated with the creation of an experimental bronchopleural fistula (BPF) treated by mechanical ventilation and thoracic drainage with or without a water seal. METHODS: Six large white pigs weighing 25 kg each which, after general anesthesia, underwent endotracheal intubation (6mm), and mechanically ventilation. Through a left thoracotomy, a resection of the lingula was performed in order to create a BPF with an output exceeding 50% of the inspired volume. The chest cavity was closed and drained into the water sealed system for initial observation of the high output BPF. RESULTS: Significant reduction in BPF output and PaCO2 was related after insertion of a water-sealed thoracic drain, p< 0.05. CONCLUSION: Insertion of a water-sealed thoracic drain resulted in reduction in bronchopleural fistula output and better CO2 clearance without any drop in cardiac output or significant changes in mean arterial pressure.

Hemodynamic, ventilatory and gasometric evaluation of an experimental bronchopleural fistula

PURPOSE: To investigate the hemodynamic and ventilatory changes associated with the creation of an experimental bronchopleural fistula (BPF) treated by mechanical ventilation and thoracic drainage with or without a water seal. METHODS : Six large white pigs weighing 25 kg each which, after general anesthesia, underwent endotracheal intubation (6mm), and mechanically ventilation. Through a left thoracotomy, a resection of the lingula was performed in order to create a BPF with an output exceeding 50% of the inspired volume. The chest cavity was closed and drained into the water sealed system for initial observation of the high output BPF. RESULTS: Significant reduction in BPF output and PaCO2 was related after insertion of a water-sealed thoracic drain, p< 0.05. CONCLUSION: Insertion of a water-sealed thoracic drain resulted in reduction in bronchopleural fistula output and better CO2 clearance without any drop in cardiac output or significant changes in mean arterial pressure. .

Preoperative hypoalbuminemia is a risk factor for late bronchopleural fistula after pneumonectomy.

BACKGROUND: Pneumonectomy is still a high-risk surgical procedure. Postpneumonectomy bronchopleural fistula is an especially severe complication with a high mortality rate. Although several reports have discussed risk factors for early bronchopleural fistula after pneumonectomy, only a few have reported them for late bronchopleural fistula. We reviewed cases of late bronchopleural fistula after pneumonectomy and investigated its risk factors. METHODS: Sixty-four patients with nonsmall cell lung cancer underwent pneumonectomy at our institution from June 1999 to December 2004. Among them, 5 who developed bronchopleural fistula were investigated. RESULTS: All of the 5 patients were male; 3 had undergone right pneumonectomy and 2 left pneumonectomy. The period between surgery and the appearance of bronchopleural fistula ranged from 36 to 164 days. We found that the preoperative serum albumin level was significantly lower in the patients with late bronchopleural fistula. Induction therapy, surgical side, age, anemia, arterial blood oxygen, and respiratory function did not affect the occurrence of bronchopleural fistula after pneumonectomy. CONCLUSIONS: A preoperative low-serum albumin level, indicative of poor nutritional status, is a risk factor for late bronchopleural fistula after pneumonectomy for nonsmall cell lung cancer.

Preoperative serum fibrinogen level predicts postoperative pulmonary complications after lung cancer resection.

BACKGROUND: Patients undergoing pulmonary resection are thought to be at high risk for the development of postoperative pulmonary complications (PPCs), and these complications may lead to serious morbidity. The purpose of this study was to identify the factors associated with postoperative pulmonary complications in patients undergoing lung cancer resection and to determine the effect of PPCs on survival. METHODS: The study involved a retrospective review of 635 patients who had undergone curative resection for lung cancer. The patient group included 504 males (79.4%), and the overall mean age was 61.3 years. Patients were classified as those who had experienced PPCs (PPCs group, n = 105, 16.5%) or those who had not (no-PPCs group, n = 530, 83.5%). RESULTS: The surgical procedures performed were 101 pneumonectomies (15.9%), 505 lobectomies (79.5%), and 29 lesser resections (4.6%). Cancer types comprised 330 squamous cell carcinomas (52.0%), 255 adenocarcinomas (40.2%) and 50 others (7.8%). Univariate analysis showed that the following factors were predictors for PPCs: male sex, erythrocyte sedimentation rate, preoperative serum fibrinogen level, pulmonary function, chronic obstructive pulmonary disease, smoking, double primary cancer, and surgical duration. Multivariate logistic regression showed that preoperative serum fibrinogen level (p < 0.001), surgical duration (p < 0.0001) and being male (p = 0.02) were significant predictors of PPCs. Overall survival 3 years after surgery was 68.2% in no-PPCs group and 38.8% in PPCs group (p < 0.0001). Regardless of tumor staging, overall survival differed significantly between PPCs and no-PPCs groups, whereas disease-free survival did not. CONCLUSIONS: Higher preoperative serum fibrinogen levels, longer surgical duration, and being male were the predictive factors for PPCs in surgical candidates. The development of PPCs was linked to a shortened overall survival.

A case of bronchopleural fistula detected by monitoring plasma endothelin-1.

Levels of endothelin (ET)-1 peptide are transiently increased after major physical stress. While studying sequential changes in plasma ET-1 levels during various types of stress, we noticed that the level of plasma ET-1 began to rise 10 days post-operatively in one patient with lung cancer who had undergone a left lower lobectomy. 35 days postoperatively a bronchopleural fistula became clinically manifest. The case is presented and the use of plasma ET-1 as an indicator is discussed.

Management of malignant air leak in a child with a neonatal high-frequency oscillatory ventilator.

A 10-year-old, 36-kg child with a malignant air leak who failed conventional mechanical ventilation and high-frequency jet ventilation was successfully treated with a neonatal high-frequency oscillatory ventilator for 31 days. Since the air leak resolved with minimal hemodynamic compromise, this technique may have application in the management of respiratory failure and air leak in the older and larger child for prolonged periods of time.

Ultra-high-frequency jet ventilation in a bronchopleural fistula model.

High-frequency ventilation techniques have been demonstrated to be useful in decreasing gas loss from bronchopleural fistulas. We performed the present study to evaluate the impact of a new jet ventilator design and ventilatory frequency on hemodynamics, gas exchange, and bronchialstump gas flow in an animal model of bronchopleural fistula. Ten pigs underwent a right-sided thoracotomy and right-sided upper pulmonary lobectomy with cannulation of the upper lobe bronchus for measurement of bronchial fistula flow rate. Animals underwent a random sequence of conventional ventilation (12 to 20 breaths per minute), conventional high-frequency jet ventilation (120 breaths per minute), and ultra-high-frequency jet ventilation (UHFJV; 450 breaths per minute). Hemodynamic measurements were similar in the three ventilatory modes, but oxygenation was best with UHFJV. Bronchial fistula flow was lowest with UHFJV and greatest with conventional ventilation. Ultra-high-frequency jet ventilation demonstrated superior oxygen loading, adequate carbon dioxide elimination, and the least flow through the fistula, suggesting that both ventilator design and frequency are important therapeutic variables in the management of major airway disruption.

Changes in the respiratory gas tensions of a pneumonectomy space and their application to the diagnosis of bronchopleural fistula.

The oxygen (pO2) and carbon dioxide (pCO2) gas tensions of a pneumonectomy space were studied in an animal model. The 2 gases were measured in a standard blood gas analyser. The space gas pO2 and pCO2 equilibrated to a steady state within 48 hours of thoracotomy (pO2 mean 53.9 +/- 9.3 SD torr; pCO2 mean 44.8 +/- 9.9 SD torr). In the presence of a bronchopleural fistula (BPF), the pO2 rose significantly (mean pO2 118.4 +/- 13.2 SD torr; p less than 0.001). The space pCO2 usually fell, but the response was inconsistent (mean pCO2 33.6 +/- 16.4 SD; p = NS). A further rise in space pO2 could sometimes be induced by allowing the animals to breathe 100% oxygen by face mask. Data from 4 clinical cases of BPF support the concept that measurement f the space gas pO2 could be used as a bedside test for BPF.