Bronchoscopic Blood Patch for Treatment of Persistent Alveolar-Pleural Fistula

Abstract

Airway pleural fistulas remain a significant treatment challenge despite improved antimicrobial therapy and surgical techniques. We present a case of a 56-year-old female who was admitted with severe bilateral cavitary pneumonia requiring mechanical ventilation. The patient suffered bilateral pneumothoraces related to necrotic pneumonia resulting in bilateral chest tube placement. Despite conservative measures, the air leak persisted preventing chest tube removal. Bronchoscopy with Fogarty balloon (Edwards) occlusion was performed in attempts to isolate an airway responsible for the air leak. No one single airway could be bronchoscopically occluded to isolate the right-sided fistula. Efforts were focused on the left airway where the fistula could be isolated to the anteromedial basal segment. Several alternating layers of an absorbable hemostat (knitted fabric prepared by controlled oxidation of cellulose-Surgicel; Ethicon) were placed within the left anteromedial basal segment using bronchoscopy forceps. Through a cut Fogarty balloon, 3 mL of the patient's blood was delivered onto the absorbable hemostat to create an occluding blood patch. No air leak was present at the completion of the procedure. While on mechanical ventilation, the left chest tube was removed 2 days later without radiographic recurrence of her pneumothorax.

Management of Persistent Air Leaks Using Endobronchial Autologous Blood Patch and Spigot Occlusion: A Multicentre Randomized Controlled Trial in China

“…The instillation of autologous blood through a chest tube for the successful management of PAL was first documented by Robinson in 1987, with a success rate of 85% in 25 patients with difficult, chronic, or recurrent pneumothoraces [30]. Endoscopic catheter-guided delivery of autologous blood was described by Wiaterek et al [16]. Simultaneously, thrombin could be applied to promote blood clotting in the lung to enhance the seal effect [19].…”

“…Among the sealants reported are autologous blood [15, 16], fibrin glue [24], cyanoacrylate glue [25, 26], oxidized cellulose [27], albumin-glutaraldehyde glue [28], and hydrogel [29]. Autologous blood was used as the injection material to treat pneumothorax and PAL, not only because of its favourable bioadhesive properties, but also because it is relatively safe and is easily archived [15].…”

“…Two of the most representative and easy approaches are autologous blood patch (ABP) [15, 16] and bronchial occlusion using silicone spigots (BOS) [17, 18]. ABP helps to seal air leaks with blood components that can initiate and support a fibrinous and inflammatory response [16].…”

Bronchoscopic management of prolonged air leak

“…Wiaterek and colleagues reported a patient with necrotizing pneumonia complicated by pneumothorax and PAL. Using flexible bronchoscopy and forceps, several layers of a hemostatic agent were applied first (Surgicel ® , Ethicon, Piscataway, NJ, USA) followed by instillation of 3 mL of autologous blood via a modified Fogarty ® balloon catheter, resulting in immediate cessation of air leak (80). The pleural drain was removed after two days.…”

Minimally invasive closure of bronchopleural fistulae with novel closure devices: Fantasy or reality?

“…A laundry list of materials and devices have been tried, including lead shots, glues (cyanoacrylate), bioglues, Gelfoam (Pfizer, New York, NY), various modified stents, and endobronchial valves. [4][5][6][7][8][9][10] After the introduction of patent foramen ovale and atrial septal defect closure devices, such as the Amplatzer (St. Jude Medical, St. Paul, Minn) and Occlutech Figulla (Occlutech, Helsingborg, Sweden), reports began surfacing that use these or similar individually constructed devices in the transbronchial closure of BPFs. [9][10][11] For instance, Fruchter and colleagues 11 reported successful closure of BPF in 30 of 31 patients using the Amplatzer devices and vascular plugs.…”