Getting the Wind Knocked out of Your Chest: A Case of Endobronchial Valve Placement for Bronchocutaneous Fistula Following Thoracoplasty for Pulmonary Tuberculosis and Aspergillosis

Abstract

INTRODUCTION: Bronchopleural fistula (BPF) is cause for significant morbidity and mortality following pulmonary resection, complicated pleural infection or pneumothorax. Several methods exist for the treatment of BPF ranging from conservative methods to more invasive surgical correction. Endobronchial valve (EBV) placement is a promising minimally invasive technique for poor surgical candidates. CASE PRESENTATION: A 61-year-old male was diagnosed with pulmonary tuberculosis following a trip to Mexico in 2013 and initiated on RIPE therapy, later converted to Rifampin and Isoniazid after sputum clearance. His course was complicated by pulmonary aspergillosis and empyema with significant left upper lobe (LUL) destruction requiring thoracoplasty with Eloesser flap. Several months later he was hospitalized for sepsis and found to have a BPF for which he underwent muscle flap closure. Upon follow-up, he was noted to have a large extrapulmonary air pocket that varied with inspiration. A large BPF between the LUL and lingula was confirmed by bronchoscopy. He was deemed to be a poor repeat surgical candidate due to suboptimal nutritional status and debility so a less invasive intervention was favored. In December 2014 the patient underwent bronchoscopic placement of a removable 7.0mm Spiration IBV valve. At one month follow up there was significant reduction in the extrapulmonic air accumulation (shown). DISCUSSION: Endobronchial valves were first designed for bronchoscopic lung volume reduction in patients with severe emphysema and air trapping. More recently they were approved by the FDA under the Humanitarian Device Exemption for use in persistent air leaks (PAL) following lung resection. Off-label use for BPF or PAL secondary to suppurative lung infection or spontaneous pneumothorax have become increasingly popular owing to the minimally invasive technique. One-way EBV's work by blocking airflow distal to the valve promoting atelectasis and healing of the BPF while permitting clearance of airway secretions without affecting valve migration. CONCLUSION(S): This is a novel report of the successful use of one-way EBV for a large proximally located BPF after definitive closure was attempted with a muscle flap. Further trials are needed to establish guidelines regarding indications for use, optimal duration and prognosis after placement in such situations.