Summary
Bronchopleural fistula is a complication of lung surgery or infectious or malignant lung disease. Management of these fistulas remains an unsolved problem in ventilated patients and no “gold standard” treatment has been established to date. Various nonsurgical and surgical techniques have been described, but there is no generally accepted or evidence based treatment strategy. We describe the case of a 74- year-old man, suffering from idiopathic kappa-cryoglobulinemia for more than 10 years. As a consequence of his underlying disease he developed lobar pneumonia, pneumothorax and a large bronchopleural fistula of the right middle lobe bronchus. Despite continuous intercostal chest drainage and a lung protective ventilation strategy we neither achieved control of the air leak nor closure of the fistula in the first two weeks of treatment. In order to identify the origin of the bronchopleural fistula, a 4F Fogarty embolectomy catheter was inserted into the right middle lobe bronchus under continuous radiological control and, in order to close the air leak, was blocked afterwards. In addition, a blood clot was administered through the embolectomy catheter to seal the large liquid-filled cavity distal to the bronchus block. Nevertheless, only partial occlusion of the fistula could be achieved. Complete and long-lasting occlusion of the fistula was possible after the right middle lobe bronchus was additionally occluded by oxidized regenerated cellulose proximal to the bronchus block via a flexible bronchoscope. We conclude that closure of large bronchopleural fistulas is achievable by a combination of three “geasy to use” techniques and discuss this case in context with previous publications.
Zusammenfassung
Das Auftreten einer bronchopleuralen Fistel stellt nach wie vor eine intensivmedizinische Problemsituation dar, für die bislang keine einheitlichen Behandlungsstandards entwickelt werden konnten. Dies wird durch die große Vielzahl der in der Literatur vorgeschlagenen problemlösenden Maßnahmen verdeutlicht. Mit einer Inzidenz von 0,8 bis 15% der Fälle treten bronchopleurale Fisteln als Komplikation in der Thoraxchirurgie auf. Ohne vorausgehendes OP-Trauma entwickeln sie sich meist im Zusammenhang mit pulmonalen bakteriellen Infektionen auf dem Boden unterschiedlicher Grunderkrankungen. Wir beschreiben den Fall eines Patienten mit plasmapherese-pflichtiger IgM/IgG-Kappakryoglobulinämie, bei dem es als Folge einer abszedierenden Staphylokokkenpneumonie zur Ausbildung eines Pneumothorax mit großer bronchopleuraler Fistel im Bereich des rechten Mittellappens kam. Trotz mehrfacher Drainage und Anwendung einer lungenprotektiven Beatmung konnte die Fistel, deren Leckagevolumen bis zu 50% des Tidalvolumens betrug, zunächst nicht geschlossen werden. In einem zweizeitigen Vorgehen wurde daher der zuführende Lappen- Bronchus mit Hilfe eines Fogarty-Ballon-Katheters geblockt, eine distal des Ballons gelegene Seromhöhle mit einem Eigenblutpatch gefüllt und letztlich der Bronchus proximal des Ballonkatheters mit oxidierter regenerierter Cellulose abgedichtet. Durch diese Kombination konservativer Maßnahmen konnte ein dauernder Fistelverschluss erreicht werden. Die beschriebene Behandlungsmethode wird im Zusammenhang mit einer ausführlichen Literaturdarstellung diskutiert.
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Hofmann-Kiefer, K., Kunze-Kronawitter, H., Angstwurm, M. et al. Verschluss einer bronchopleuralen Fistel durch die kombinierte Anwendung von Bronchusblockade, Blutpatch und oxidierter regenerierter Cellulose. Intensivmed + Notfallmed 42, 53–59 (2005). https://doi.org/10.1007/s00390-005-0566-0
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DOI: https://doi.org/10.1007/s00390-005-0566-0