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A New Way to See a Bronchopleural Fistula

Accepted version
Peer-reviewed

Type

Article

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Authors

Sivasothy, Pasupathy 

Abstract

A 77-year-old man presented with five episodes of sepsis to different hospitals in the year after having a left lower lobectomy for squamous cell carcinoma. In the first two episodes, a rim-enhancing left pleural effusion was seen and drained under computed tomography guidance. In his third and subsequent episodes, the effusion was noted as being present but was considered too small and loculated to drain effectively. His admission chest radiograph at his fifth presentation, which showed nonspecific changes at the left base, is shown in Figure 1A. Computed tomography and bronchoscopy failed to demonstrate a bronchopleural fistula. Therefore, we combined both techniques. The patient underwent bronchoscopy in a near-upright position under conscious sedation with midazolam. At bronchoscopy, 15 ml of Niopam 300 (an iodine-containing contrast agent routinely used in computer tomography enhancement, angiography, and arthrography) was diluted with an equal volume of sterile normal saline to reduce its viscosity. Three 10-ml aliquots of diluted Niopam 300 were gently injected by hand over 5 minutes into the left lower bronchial stump under fluoroscopic guidance (Figure 1B). Contrast was seen pooling passively in a cavity as well as extending in an arboreal pattern into the bronchi (Figure 1C). Subsequent bronchoalveolar lavage was performed with 120 ml sterile normal saline and aspirated to dryness. Fluoroscopy demonstrated residual contrast in a pleural-based cavity (Figure 1D), whereas the arboreal pattern was lost, indicating washout of contrast from the airways. The patient was observed in the bronchoscopy recovery area for 2 hours and then sent to the radiology suite. Finally, computed tomography after the bronchoscopy provided definitive proof of a fistula (Figure 1E).

Description

Keywords

Aged, Bronchial Fistula, Bronchoscopy, Contrast Media, Fistula, Humans, Iopamidol, Male, Pleural Diseases, Radiographic Image Enhancement, Tomography, X-Ray Computed

Journal Title

American Journal of Respiratory and Critical Care Medicine

Conference Name

Journal ISSN

1073-449X
1535-4970

Volume Title

194

Publisher

American Thoracic Society

Rights

All rights reserved