LETTER: CLINICAL OBSERVATION
Endobronchial Oxygen Insufflation: A Novel Technique for Localization
of Occult Bronchopleural Fistulas
Macarena Rodriguez Vial1, Charlie Lan2, Lorraine Cornwell3, Shuab Omer3, and Roberto F. Casal2
1
Division of Pulmonary Medicine, Clinica Alemana de Santiago, Universidad del Desarrollo, Santiago, Chile; and 2Division of Pulmonary
and Critical Care Medicine and 3Department of Thoracic Surgery, The Michael E. DeBakey VA Medical Center, Baylor College of
Medicine, Houston, Texas
Case 1
A 61-year-old man underwent video-assisted thoracic surgery to
resect the right lower lobe for treatment of a stage IIb
adenocarcinoma of the lung. After the procedure, a chest radiograph
demonstrated a small, loculated, right-sided pneumothorax,
which was confirmed by computed tomographic imaging
(Figure 1A). A 14F chest tube was placed, a small amount of fluid
was evacuated, and an air leak was seen intermittently during
passive expiration.
Bronchoscopy was performed to evaluate the stump and to
look for a potential bronchopleural fistula. The right lower lobe
stump appeared intact (Figure 2A). Because the air leak was not
active during bronchoscopy, selective balloon occlusion for
localization of the fistula was not feasible.
To locate the fistula, low-flow oxygen (2 l/min) was attached to
the suction port of the flexible bronchoscope (Figure 3). Oxygen
was insufflated in 2-second bursts selectively, first to the right lower
lobe stump and then sequentially to the right middle lobe and right
upper lobe bronchi by triggering what typically works as the
“suction” valve on the bronchoscope. Bubbling at the underwater
seal was only seen when oxygen was insufflated at the right lower
lobe stump and not at any other site. The bronchial stump was
sealed with cyanoaccrylate glue as previously described. The
chest tube was removed uneventfully 4 days after fluid output
subsided.
Case 2
A 73-year-old man underwent a right upper lobectomy and
a right lower lobe wedge resection for a known right upper lobe
adenocarcinoma and a suspicious right lower lobe nodule.
Postoperatively, there was an intermittent air leak. A persistent,
small, right apical pneumothorax expanded when the chest tubes
were clamped.
Bronchoscopy was performed in an attempt to locate and
manage the defect. Despite application of positive pressure
ventilation, the air leak became smaller and more intermittent
than before the procedure, precluding balloon occlusion for
localization of the air leak. Endobronchial oxygen insufflation
was then performed, and a large air leak was apparent when the right
middle lobe was insufflated. The right middle lobe bronchus was
occluded using an endobronchial valve (1). Postprocedure imaging
demonstrated resolution of the apical pneumothorax. Within
48 hours, both chest tubes were removed, and the patient was
subsequently discharged home.
Figure 1. (A) Computed tomographic image of the chest showing loculated pneumothorax and effusion in right base of the lung. (B) Computed
tomographic image of the chest after sealing of bronchopleural fistula, with resolution of pneumothorax.
Ann Am Thorac Soc Vol 10, No 2, pp 157–159, Apr 2013
Copyright ª 2013 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201212-126OT
Internet address: www.atsjournals.org
Letter: Clinical Observation
157
LETTER: CLINICAL OBSERVATION
Figure 2. (A) Right lower lobe stump without any visible major defect. (B) Bronchial stump sealed with cyanoaccrylate glue.
Discussion
Bronchopleural fistula is a relatively rare but significant complication
of pulmonary resection (2, 3). Localization of a bronchopleural fistula
can be challenging, and it is crucial to determine the most
appropriate therapeutic approach. Bronchoscopy is widely used
because it can be diagnostic and therapeutic (4). Although large
defects at the stump can be readily seen during bronchoscopy,
localization of smaller defects may require an alternative method.
Instillation of methylene blue is sometimes used. However,
methylene blue may not reach the pleural space and the chest tube
seal if the leak is small and intermittent. Also, methylene blue can
obscure the view of the stump, thereby impairing application of
a sealing technique.
Another bronchoscopic technique for locating peripheral
bronchopleural fistulas uses sequential occlusion of selected bronchi
with a balloon catheter until a decrease or cessation of the air
leak is observed. However, we have recently come across several
patients with small but persistent air leaks that “disappear” during
bronchoscopy. This phenomenon might be related to positioning
(patient and chest tube) because in a few patients we could
reproduce the air leak by sitting the patient upright. Regardless,
when air leaks are small or intermittent during bronchoscopy,
localization of the air leak by balloon occlusion technique
becomes inaccurate or impractical. To overcome this obstacle,
we developed a technique of endobronchial oxygen insufflation
of selected bronchi, as illustrated by the two cases presented
here.
One concern with gas insufflation into a lobar or segmental
airway is the potential for iatrogenic barotrauma. Airway pressures
are likely to vary in patients based on factors such as volume of
distribution of the insufflated gas and local tissue compliance. We
monitored airway pressures during oxygen insufflation using
a dedicated catheter (ACU-1938 Biro; Susquehanna Micro Inc.,
Hallam, PA) that connects to the Acutronic Monsoon III Jet
Ventilator (Susquehanna Micro Inc.). The catheter was placed
alongside the bronchoscope in the distal right bronchus
intermedius, and oxygen was insufflated immediately above the tip
at 2 l/min for 2- and 4-second periods. The airway pressure
158
remained unchanged when we insufflated oxygen for 2 seconds
and increased by 2 cm H2O when insufflated for 4 seconds.
Given that the total volume of oxygen insufflated during the 2second activation used in this technique is less than 70 ml, we
Figure 3. Oxygen tubing connected to suction port of flexible
bronchoscope. Instead of suction, this provides a jet of oxygen when
the suction valve is activated.
AnnalsATS Volume 10 Number 2 | April 2013
LETTER: CLINICAL OBSERVATION
believe the probability of clinically significant barotrauma is
minimal.
To the best of our knowledge, this is the first report of
endobronchial oxygen insufflation for the localization of occult
bronchopleural fistula. We hope our case reports will prompt further
studies on the safety and effectiveness of this technique for localizing
bronchopleural defects associated with intermittent air leaks. n
References
3 Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H.
Bronchopleural fistula in the surgery of non-small cell lung cancer:
incidence, risk factors, and management. Ann Thorac Cardiovasc
Surg 2001;7:330–336.
4 Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem
with special focus on endoscopic management. Chest 2005;128:
3955–3965.
1 Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski
RA, Musani AI, Kucharczuk JC, Gonzalez HX, Springmeyer SC.
Endobronchial valve treatment for prolonged air leaks of the lung:
a case series. Ann Thorac Surg 2011;91:270–273.
2 Cerfolio RJ. The incidence, etiology, and prevention of postresectional
bronchopleural fistula. Semin Thorac Cardiovasc Surg 2001;13:3–7.
Letter: Clinical Observation
Author disclosures are available with the text of this article at
www.atsjournals.org.
159