Combination of transbronchoscopic oxygen insufflation and a digital chest drainage system in endobronchial occlusion: a hybrid technique for localization of fistula in intractable pneumothorax.

BACKGROUND: The management of intractable secondary pneumothorax poses a considerable challenge as it is often not indicated for surgery owing to the presence of underlying disease and poor general condition. While endobronchial occlusion has been employed as a non-surgical treatment for intractable secondary pneumothorax, its effectiveness is limited by the difficulty of locating the bronchus leading to the fistula using conventional techniques. This report details a case treated with endobronchial occlusion where the combined use of transbronchoscopic oxygen insufflation and a digital chest drainage system enabled location of the bronchus responsible for a prolonged air leak, leading to the successful treatment of intractable secondary pneumothorax. CASE PRESENTATION: An 83-year-old male, previously diagnosed with chronic hypersensitivity pneumonitis and treated with long-term oxygen therapy and oral corticosteroid, was admitted due to a pneumothorax emergency. Owing to a prolonged air leak after thoracic drainage, the patient was deemed at risk of developing an intractable secondary pneumothorax. Due to his poor respiratory condition, endobronchial occlusion with silicone spigots was performed instead of surgery. The location of the bronchus leading to the fistula was unclear on CT imaging. When the bronchoscope was wedged into each subsegmental bronchus and low-flow oxygen was insufflated, a digital chest drainage system detected a significant increase of the air leak only in B5a and B5b, thus identifying the specific location of the bronchus leading to the fistula. With the occlusion of those bronchi using silicone spigots, the air leakage decreased from 200 mL/min to 20 mL/min, and the addition of an autologous blood patch enabled successful removal of the drainage tube. CONCLUSION: The combination of transbronchoscopic oxygen insufflation with a digital chest drainage system can enhance the therapeutic efficacy of endobronchial occlusion by addressing the problems encountered in conventional techniques, where the ability to identify the leaking bronchus is dependent on factors such as the amount of escaping air and the location of the fistula.

Multidisciplinary treatment of thoracic fistulous empyema caused by pulmonary infection: a retrospective study.

Background: In cases of thoracic empyema, the presence of a fistula is known to be difficult to treat and associated with a poor prognosis. Few reports have described the management of fistulous empyema caused by lung parenchymal infection. The aim of this study was to describe the outcomes of multidisciplinary management of fistulous empyema caused by pneumonia or lung abscess due to common bacteria and mycobacteria. Methods: Among 108 cases of empyema surgically treated at Kanagawa Hospital over a 10-year period, 14 patients with fistulous empyema due to common bacteria (CBFE) or fistulous empyema due to mycobacteria (MFE) were analyzed. Fistulous empyema due to lung resection was excluded. Results: Eight out of the 9 patients with CBFE and 4 out of the 5 patients with MFE were male. Patients with CBFE were more likely to be >65 years of age (p=0.052) and to have a poor performance status (p=0.078). The time from onset to first surgical treatment was significantly longer in MFE (median, 5 months; p=0.004). Five patients with CBFE and two patients with MFE underwent open window thoracostomy, while three patients with CBFE and four patients with MFE underwent endobronchial occlusion (EBO). Six patients (66%) with CBFE and 3 patients (60%) with MFE achieved fistula closure. Of the patients who underwent EBO, fistula closure was achieved in 3 (100%) of the patients with CBFE and in 2 (50%) of the patients with MFE. Fistula closure was not achieved in any case with non-tuberculous mycobacteria. Conclusions: Fistulous empyema caused by common bacteria or Mycobacterium tuberculosis could be cured by surgical treatment and endobronchial intervention with adequate antimicrobial therapy, but fistulous empyema caused by non-tuberculous mycobacteria proved to be intractable. The challenge in the treatment of fistulous empyema due to non-tuberculous mycobacteria is the achievement of bacterial negativity.

Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet's disease.

BACKGROUND: Behcet's disease is a multi-system inflammatory disorder. A small subset of patients with Behcet's develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree. CASE PRESENTATION: We present the case of a 44-year-old lady with Behcet's Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung. CONCLUSIONS: A multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet's disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.

Bronchoscopic Treatment of Giant Emphysematous Bullae with Endobronchial Silicone Plugs.

Purpose: Surgical bullectomy is the standard treatment of giant emphysematous bulla (GEB). However, bronchoscopic treatment should be considered as an alternative approach for patients who are unfit for surgical treatment. The study aimed to evaluate the clinical efficacy of endobronchial occlusion for the treatment of GEB using silicone plugs. Methods: This retrospective study recruited four patients with GEB who were unsuitable for surgery. Preoperative planning was performed using high-resolution computed tomography and a virtual bronchoscopic navigation system. Customized silicone plugs were then placed in the target airway via bronchoscopy to cause GEB regression and atelectasis. Results: All procedures were completed successfully in four patients. Three months after the procedures, compared with baseline, increases in the mean forced expiratory volume in 1 s (from 1.20 L/s to 1.33 L/s), forced vital capacity (from 2.63 L to 2.90 L), diffusion lung capacity for carbon monoxide (from 29% to 41% of the predicted value) and 6-minute walking test (from 412 m to 474 m) were observed. Additionally, the mean total lung capacity (from 6.80 L to 6.35 L), residual volume (from 3.97 L to 3.52 L), and St. George's Respiratory Questionnaire scores (from 67 to 45) were all lower than baseline data. Conclusion: Our preliminary results demonstrated that the endobronchial placement of silicone plugs could be a low-cost, safe, and effective choice for the treatment of GEB in surgically unfit patients.

Successful endobronchial occlusion in empyema with broncho-pleural fistula secondary to COVID-19 pneumonia: a case report and literature review.

A few cases of empyema secondary to coronavirus disease 2019 (COVID-19) pneumonia have been reported. Here, we report our experience of a successful endobronchial occlusion using endobronchial Watanabe spigots (EWSs) for empyema with broncho-pleural fistula secondary to COVID-19 pneumonia. A 62-year-old man was diagnosed with COVID-19 and progressed to empyema with broncho-pleural fistula. Computed tomography (CT) imaging showed cyst formation and the right B5b was presumed to be a branch dependent on the cyst. The effusion and air in the pleural cavity were well drained, although the air leak persisted. Endobronchial occlusion was performed for right B5a and B5b using 7- and 5-mm EWSs (Novatech, France), respectively, and the air leak ceased. This is the first report of successful treatment of empyema with bronchial fistula with endobronchial occlusion. Air leak secondary to COVID-19 pneumonia with a limited number of air cysts may be a good indication for endobronchial occlusion.