Bronchoscopic management in persistent air leak: a narrative review.

Background and Objective: Persistent air leak (PAL) represents a challenging medical condition characterized by prolonged air leak from the lung parenchyma into the pleural cavity, often associated with alveolar-pleural fistula or bronchopleural fistula (BPF). The objective of this narrative review is to explore the causes, clinical implications, and the evolving landscape of bronchoscopic treatment options for PAL. Methods: The literature search for this review was conducted using databases such as PubMed/MEDLINE, and Scopus databases. Articles published from inception until 28th August, 2023, focusing on studies that discussed the causes, diagnosis, and management strategies for PAL were included. Keywords included bronchoscopic management, bronchopleural fistula, endobronchial valve, sealant, blood patch pleurodesis, spigot, air leak, PAL, management, comparative study. Key Content and Findings: PAL commonly arises from secondary spontaneous pneumothorax, necrotizing pneumonia, barotrauma induced by mechanical ventilation, chest trauma, or postoperative complications. Understanding the underlying etiology is crucial for tailoring effective management strategies. While conventional intercostal drainage resolves the majority of pneumothorax cases, PAL is diagnosed when the air leak persists beyond 5 to 7 days. Prolonged PAL can lead to worsening pneumothorax, respiratory distress, and increased morbidity. Early identification and intervention are essential to prevent complications. Conservative approaches involve close monitoring and supplemental oxygen therapy. These strategies aim to promote natural healing and resolution of the air leak without invasive interventions. Bronchoscopic techniques, such as endobronchial valves (EBVs), sealants, and autologous blood patch (ABP), have emerged as promising alternatives for refractory PAL. These interventions offer a targeted and minimally invasive approach to seal the fistulous connection, promoting faster recovery and reducing the need for surgical interventions. Conclusions: PAL is a clinical challenge, and their management requires a tailored approach based on the underlying cause and severity. Bronchoscopic interventions have shown efficacy in cases of refractory PAL. Early recognition, multidisciplinary collaboration, and a personalized treatment plan are essential for optimizing outcomes in patients with PAL.

Primary renal mucormycosis in a type 2 diabetic patient: A case report from Syria.

Mucormycosis is an opportunistic fungal infection that primarily affects immunocompromised individuals and rarely presents as renal mucormycosis (RM). Diagnosis can be challenging for many physicians. We report a rare case of primary, unilateral RM which triggered diabetic ketoacidosis in a type 2 diabetic patient. The case was later complicated by a bronchopleural fistula and a meropenem-resistant Klebsiella infection. The patient was ultimately treated with surgical intervention, liposomal amphotericin B, and polymyxine E. Early diagnosis and timely treatment of this life-threatening disease and its complications are significant in reducing mortality.

Embolization coils in treating postoperative bronchopleural fistula: a systematic review.

Objective: This study aims to comprehensively evaluate embolization coils in treating postoperative bronchopleural fistula (BPF). Methods: A systematic review based on PubMed, Embase, and The Cochrane Library studies was conducted. All cases receiving embolization coils in treating postoperative BPF were included. The primary outcome was the efficacy of embolization coils in achieving closure of postoperative BPF. Results: 20 patients from 9 studies were included in this systematic review. A median number of 3 (range: 1-10) embolization coils with sealants obtained a complete closure rate of 80% in patients with postoperative BPF with sizes ranging from 2 to 3.1 mm. Three patients with BPF over 3 mm and one with multiple organ failure failed this treatment. Two cases of coil migration were reported without causing respiratory failure or fistula recurrence. Conclusion: Embolization coils might be considered a safe and effective bronchoscopic treatment for small postoperative BPF of less than 3 mm in size. More extensive and rigorous studies are needed to further evaluate and confirm the optimal use of embolization coils in the context of an alternative to surgical repair.

Hydropneumothorax in a non-small cell lung cancer patient after lobectomy due to surgical stump air leak.

Hydropneumothorax following lobectomy or pneumonectomy is relatively uncommon, with an incidence of 1%-5%. It involves air and fluid in the pleural cavity, often due to intraoperative injury, infection, bronchopleural fistula, or mechanical ventilation. Careful management, including drainage and addressing the underlying cause, is essential to prevent serious outcomes.

Treatment of late left bronchopleural fistula after left pneumonectomy through right thoracic approach assisted by extracorporeal membrane oxygenation.

BACKGROUND: Bronchopleural fistula (BPF) is a rare but fatal complication after pneumonectomy. When a BPF occurs late (weeks to years postoperatively), direct resealing of the bronchial stump through the primary thoracic approach is challenging due to the risks of fibrothorax and injury to the pulmonary artery stump, and the surgical outcome is generally poor. Here, we report a case of late left BPF following left pneumonectomy successfully treated using a right thoracic approach assisted by extracorporeal membrane oxygenation (ECMO). CASE PRESENTATION: We report the case of a 57-year-old male patient who underwent left lower and left upper lobectomy, respectively, for heterochronic double primary lung cancer. A left BPF was diagnosed at the 22nd month postoperatively, and conservative treatment was ineffective. Finally, the left BPF was cured by minimally invasive BPF closure surgery via the right thoracic approach with the support of veno-venous extracorporeal membrane oxygenation (VV-ECMO). CONCLUSIONS: Advanced BPF following left pneumonectomy can be achieved with an individualized treatment plan, and the right thoracic approach assisted by ECMO is a relatively simple and effective method, which could be considered as an additional treatment option for similar patients.

Percutaneous Drainage of Pediatric Pulmonary Abscesses: An Effective Therapy.

INTRODUCTION: Pulmonary abscess is a complication of lung infection with localized necrosis and purulent cavity formation. Pulmonary abscesses are typically managed using antibiotic therapy with anatomic surgical resection reserved as a rescue. Percutaneous drainage is considered relatively contraindicated in some centers due to perceived risk of bronchopleural fistula. However, drain placement has been frequently employed at our institution. The purpose of this study was to review and describe our longitudinal experience. METHODS: Medical records of children diagnosed with lung abscess and treated with percutaneous drainage from 2005 through 2023 were reviewed. Patient clinical parameters, follow-up imaging, and clinical outcomes were evaluated. RESULTS: Percutaneous drainage (n = 24) or aspiration alone (n = 4) under imaging guidance was performed by interventional radiologists for 28 children with lung abscesses. A single catheter (8-12 Fr) was deployed in the pulmonary abscess cavity and remained for a median of 6 days (IQR: 6-8 days). The median hospital stay was 10 days (IQR: 8.8-14.8 days). The technical success rate for percutaneous drainage or aspiration of primary pulmonary abscesses was 100% (26/26). Two children were later diagnosed with secondarily infected congenital pulmonary airway malformations that were both successfully drained and ultimately surgically resected. The abscess cavities resolved in all patients and catheters were removed upon clinical, radiographic, and laboratory improvement. Complications included the presence of two bronchopleural fistula, both of which were treated with immediate pleural drain placement. CONCLUSION: Percutaneous drainage of pulmonary abscesses is an effective therapeutic option in children and can be considered alongside antibiotics as part of the initial treatment for pulmonary abscesses. Bronchopleural fistula can occur, but at a lower frequency than previously reported. LEVEL OF EVIDENCE: Level V.

Case report: Endobronchial closure of postoperative bronchopleural fistula with embolization coil: a sandwich-like approach.

Background: Embolization Coil has been reported to effectively treat postoperative bronchopleural fistula (BPF). Little detailed information was available on computer tomography (CT) imaging features of postoperative BPF and treating procedures with pushable Embolization Coil. Objective: We aimed to specify the imaging characteristics of postoperative BPFs and present our experience treating them with the pushable Embolization Coil. Methods: Six consecutive patients (four males and two females aged 29-56 years) diagnosed with postoperative BPF receiving bronchoscopic treatment with the pushable Nester® Embolization Coil (Cook Medical, Bloomington, Indiana) were included in this single-center, retrospective study. Multiplanar reconstruction of multidetector CT scans was reviewed for the presence, location, size, and radiological complications of each BPF, including air collection, pneumothorax, bronchiectasis, and chest tube. Using standardized data abstraction forms, demographic traits and clinical outcomes were extracted from the medical files of these patients. Results: The underlying diseases for lung resection surgery were pulmonary tuberculosis (n = 3), lung adenocarcinoma (n = 2), and pulmonary aspergillosis (n = 1). All patients had air or air-fluid collection with chest tubes on radiological findings. Multiplanar reconstruction identified the presence of postoperative BPF in all patients. Five fistulas were central, located proximal to the main or lobar bronchus, while one was peripheral, distant from the lobar bronchus. Fistula sizes ranged from 0.8 to 5.8 mm. Subsequent bronchoscopy and occlusion testing confirmed fistula openings in the bronchial stump: right main bronchus (n = 1), right upper lobe (n = 2), and left upper lobe (n = 3). The angioplasty catheter-based procedure allows precise fistula occlusion "like a sandwich" with the pushable Embolization Coil. Five patients with BPF sizes ranging from 0.8 to 1.5 mm were successfully treated with a pushable Embolization Coil, except for one with a BPF size of 5.8 mm. No adverse events or complications were observed throughout follow-up, ranging from 29 to 1,307 days. Conclusion: The pushable Nester® Embolization Coil seems a minimally invasive, cost-effective, and relatively easy-to-perform bronchoscopic treatment for postoperative BPF with a size less than 2 mm. Further studies are required to ensure the use of pushable Embolization Coil in treating postoperative BPF.

[Retrospective Study of Bronchoscopic Intervention Therapy for Bronchopleural Fistula Induced by Pulmonary Surgery].

BACKGROUND: As a new technique developed in recent years, bronchoscopic intervention therapy has the advantages of minimal invasion, high safety and repeatability. The aim of this study is to investigate the clinical characteristics of bronchopleural fistula (BPF) induced by surgeries for lung malignancies or benign diseases and the effect of bronchoscopic intervention therapy for BPF, so as to provide support for prevention and treatment of BPF. METHODS: Data 64 patients with BPF who were treated by bronchoscopic intervention in Respiratory Disease Center of Dongzhimen Hospital, Beijing University of Chinese Medicine from June 2020 to September 2023 were collected. Patients with fistula diameter ≤5 mm were underwent submucous injection of macrogol, combined with blocking therapy with N-butyl cyanoacrylate, medical bioprotein glue or silicone prosthesis. Patients with fistula diameter >5 mm were implanted with different stents and cardiac occluders. Locations and characteristics of fistulas were summarized, meanwhile, data including Karnofsky performance status (KPS), shortbreath scale (SS), body temperature, pleural drainage volume and white blood cell count before and after operation were observed. RESULTS: For all 64 patients, 96 anatomic lung resections including pneumonectomy, lobectomy and segmentectomy were executed and 74 fistulas occurred in 65 fistula locations. The proportion of fistula in the right lung (63.5%) was significantly higher than that in the left (36.5%). Besides, the right inferior lobar bronchial fistula was the most common (40.5%). After operation, KPS was significantly increased, while SS, body temperature, pleural drainage volume and white blood cell count were significantly decreased compared to the preoperative values (P<0.05). By telephone follow-up or readmission during 1 month to 38 months after treament, median survival time was 21 months. 33 patients (51.6%) showed complete response, 7 patients (10.9%) showed complete clinical response, 18 patients (28.1%) showed partial response, and 6 patients (9.4%) showed no response. As a whole, the total effective rate of bronchoscopic intervention for BPF was 90.6%. CONCLUSIONS: BPF induced by pulmonary surgery can lead to severe symptoms and it is usually life-threating. Bronchoscopic intervention therapy is one of the fast and effective therapeutic methods for BPF.

Complex bronchopleural fistulas: a case report.

Bronchopleural fistula (BPF) is a potentially fatal complication and remains a surgical challenge. Concomitant problems, such as pulmonary infection and respiratory failure, are typically the main contributors to mortality from BPF because of improper contact between the bronchial and pleural cavity. We present the case of a 75-year-old male patient with a history of right upper lobe lung cancer resection who developed complex BPFs. Following appropriate antibiotic therapy and chest tube drainage, we treated the fistulas using endobronchial valve EBV placement and local argon gas spray stimulation. Bronchoscopic treatment is the preferred method for patients who cannot tolerate a second surgery because it can help to maximize their quality of life. Our treatment method may be a useful reference for treating complex BPF.

Development of postoperative bronchopleural fistula after neoadjuvant immunochemotherapy in non-small cell lung cancer: case reports and review of the literature.

BACKGROUND: The advent of immune checkpoint inhibitors has dramatically changed the treatment paradigm for advanced non-small-cell lung cancer (NSCLC). Due to the complexity and diversity of stage III disease, the inclusion of immune checkpoint inhibitors (ICIs) in neoadjuvant treatment regimens is also required. However, immune-related adverse events (irAEs) limit the application of ICIs to a certain extent. Bronchopleural fistula (BPF) is a serious and fatal complication after pneumonectomy that is rarely reported, especially in patients who accept neoadjuvant immunotherapy or chemoimmunotherapy. CASE PRESENTATION: Herein, we reported four patients with postoperative BPF who received a neoadjuvant regimen of sintilimab plus chemotherapy. Postoperative BPF occurred in the late stage in three patients; one patient underwent bronchoscopic fistula repair, and the fistula was closed well after surgery, and the other two patients gradually recovered within 1-2 months after symptomatic treatment with antibiotics. One patient with BPF after left pneumonectomy died of respiratory failure due to pulmonary infection. We also reviewed the literature on the development of postoperative BPF in patients receiving immuno-neoadjuvant therapy to discuss the clinical process further, postoperative pathological changes, as well as risk factors of BPF patients. CONCLUSIONS: Central type lung cancer with stage III may be the risk factors of BPF in cases of neoadjuvant immunochemotherapy for lung cancers patients.

Are precautions actually a risk factor in the development of bronchopleural fistula after pneumonectomy? A retrospective analysis of 299 cases.

PURPOSE: Bronchopleural fistula most commonly occurs after pneumonectomies, with high morbidity and mortality. A preventive approach is essential. Risk factors can be classified depending on the patient, anatomy, surgical technique, and other causes. METHODS: Patients (n = 370) who underwent pneumonectomy between 2010 and 2020 were evaluated. The digital media and archive files of the patients (n = 299) were reviewed retrospectively. RESULTS: While 271 patients (90.6%) were male, 28 (9.4%) were female. The mean age was 56.63 years. The bronchopleural fistula rate was 14.7% (44/299). Serum protein deficiency, right pneumonectomy, completion pneumonectomy, bronchial manual suturing, advanced stage, prolongation of time after neoadjuvant therapy, length of drain and hospital stay, tissue support for the stump, and short bronchial stump were significant for bronchopleural fistula. Smoking in patients operated on for malignancy and low serum albumin value in benign and chronic infectious diseases were significant in terms of fistula. In patients who developed bronchopleural fistula, the 5-year survival rate was 18.4%. CONCLUSION: The most important risk factors in bronchopleural fistula depend on the surgical technique and so are completely preventable. Contrary to the literature, short stump and tissue support to the stump were found to be risk factors for fistula. In addition, the effect of the time between neoadjuvant therapy and operation should be examined in further studies.

A novel approach involving reversed placement of endobronchial valves combined with retrograde methylene blue instillation for the localization of multifocal bronchopleural fistula.

The bronchopleural fistula (BPF) is a pathological communication between the bronchus and the pleural space. Diagnosing BPF poses a significant challenge for physicians, particularly when identifying multifocal BPFs. Traditionally, retrograde instillation of methylene blue (MB) into the pleural cavity with simultaneous observation with a bronchoscope has been used to locate a BPF. However, MB instillation is not effective in identifying multifocal BPFs. In this article, we report a new method for locating multifocal BPFs which involves placing the endobronchial valve (EBV) in reverse combined with retrograde MB instillation. First, the thoracic cavity is filled with MB solution. Then, using bronchoscopy, the location of a BPF can be identified as the MB solution flows into the bronchus. Secondly, an EBV is deployed in reverse in the bronchus where the identified BPF is located. Retrograde MB instillation is then repeated to locate any additional BPFs until no new ones are found. Two cases were reported using this novel method to identify multifocal BPFs, and each case was ultimately diagnosed with 2 BPFs. After precisely locating all the BPFs, the EBVs are then removed and placed forward in the target bronchi for treating the BPFs. During the follow-up period, no recurrence of BPFs was observed. We conclude that reversed placement of EBVs combined with retrograde MB instillation appears to be an effective approach for locating multifocal BPFs.

Inverted Placement of Endoscopic One-Way Endobronchial Valve Combined with Gelfoam in the Closure of Bronchopleural Fistula with Empyema in a Mechanically Ventilated Patient: A Case Report.

Bronchopleural fistula (BPF) with empyema caused by severe necrotizing pulmonary infection is a complicated clinical problem that is often associated with poor general condition so surgical interventions cannot be tolerated in most cases. Here, we present the successful management of multiple BPF with empyema in a mechanically ventilated patient with aspiration lung abscess. Occlusion utilizing Gelfoam followed by endobronchial valves (EBVs) implanted inverted via bronchoscope decreased the air leaking significantly and made intrapleural irrigation for empyema achievable and safe. This is the first report of a novel way of EBV placement and the combination use with other occlusive substances in BPF with empyema in a patient on mechanical ventilation. This method may be an option for refractory BPF cases with pleural infection.

Empiric flap coverage for the pneumonectomy stump: How protective is it? A single-institution cohort study.

OBJECTIVE: To evaluate the impact of empiric tissue flaps on bronchopleural fistula (BPF) rates after pneumonectomy. METHODS: Patients who underwent pneumonectomy between January 2001 and December 2019 were included. Primary end point was development of BPF. Secondary end points were impact of flap type on BPF rates, time to BPF development, and perioperative mortality. RESULTS: During the study period, 383 pneumonectomies were performed; 93 were extrapleural pneumonectomy. Most pneumonectomy cases had empiric flap coverage, with greater use in right-sided operations (right: 97%, 154/159; left: 80%, 179/224, P < .001). Empiric flaps harvested included intercostal, latissimus dorsi, serratus anterior, omentum, pectoralis major, pericardial fat/thymus, pericardium, and pleura. BPF occurred in 10.4% of the entire cohort but decreased to 6.6% when extrapleural pneumonectomy cases were excluded; 90% (36/40) of BPFs occurred on the right side (P < .001). Median time to develop BPF was 63 days, and 90-day mortality was greater in patients with BPF (12.5% BPF vs 7.4% non-BPF, P < .0001). Intercostal muscle had the lowest rate of BPF (4.5%), even in right-sided operations (8.7%). In contrast, larger muscle flaps such as latissimus dorsi (21%) and serratus anterior (33%) had greater rates of BPF, but the sample size was small in these cohorts. CONCLUSIONS: Empiric bronchial stump coverage should be performed in all right pneumonectomy cases due to greater risk of BPF. In our series, intercostal muscle flaps had low BPF rates, even in right-sided operations. Coverage of the left pneumonectomy stump is unnecessary due to low incidence of BPF in these cases.

Mesenchymal Stromal Cell Therapy for Thoracic Surgeons: An Update.

Stem cells are undifferentiated cells presenting extensive self-renewal features and the ability to differentiate "in vitro" and "in vivo" into a range of lineage cells, like chondrogenic, osteogenic and adipogenic lineages when cultured in specific inducing media. Two major domains of clinical applications of stem cells in thoracic surgery have been investigated: regenerative medicine, which is a section of translational research in tissue engineering focusing on the replacement, renewal or regeneration of cells, tissues and organs to re-establish damaged physiologic functions; drug loading and delivery, representing a new branch proposing stem cells as carriers to provide selected districts with anti-cancer agents for targeted treatments.

Tuberculous Bronchopleural Fistula: A Rare and Life-Threatening Disease.

Tuberculous bronchopleural fistula (BPF) is a rare and potentially life-threatening complication of pulmonary tuberculosis, in which abnormal connections form between the bronchial tree and the pleural space. These abnormal connections allow air and secretions to pass from the lungs into the pleural space, causing a range of symptoms from benign cough to acute tension pneumothorax. The management of tuberculous BPF requires an individualized approach based on the patient's condition and response to treatment. Anti-tuberculosis therapy is essential for controlling the active tuberculosis infections. Intercostal drainage and suction are also commonly used to drain air and fluid from the pleural space, providing relief from the symptoms. For some patients, more invasive surgeries, such as decortication, thoracoplasty or pleuropneumonectomy are required to definitively close the fistula when medical management alone is insufficient. Herein, we describe a rare case of tuberculous BPF in a young adult female, who was treated with anti-tuberculosis medications and open thoracotomy.

Bronchopleural Fistula Management With an Amplatzer Duct Occluder: A Comprehensive Case Report and Literature Review.

Bronchial stump insufficiency (BSI), also reported as bronchopleural fistula, following pneumonectomy is a rare but potentially devastating complication that can result in substantial morbidity and mortality. Despite advances in thoracic surgical techniques and perioperative care, bronchial stump dehiscence remains a challenging clinical scenario, especially when associated with severe infections and compromised patient conditions. Traditional surgical re-intervention to address this complication may carry significant risks and might be contraindicated in certain patients. As a result, innovative interventions are necessary to address these challenging cases effectively. In this report, we present an interventional endoscopic technique using an Amplatzer Duct occluder for the successful management of BSI in a 55-year-old male patient with a complex medical history.