Journal of the Louisiana State Medical Society
Broken Lung
Ikrita K. Klair, MD; Jaime Palomino, MD; Fayez Kheir, MD; Daniel A. Salerno, MD
We report a case of severe acute respiratory distress syndrome (ARDS) complicated by a very large bron- chopleural fistula (BPF) measuring 30 mm in length and evident on computed tomography (CT) chest scan. Such a large BPF is a very rare occurrence. Generally, a BPF of more than 6 mm in size is considered as large. 1 Small BPFs can be easily missed on CT scan chest, but a persistent air-leak through an adequately placed chest tube should raise suspicion for a BPF.
INTRODUCTION Bronchopleural fistula (BPF) is a communication be- tween the pleural space and the bronchial tree. 2 BPF is a life-threatening complication usually seen after pulmonary resection. The incidence varies from 4.5% to 20% after pneu- monectomy and is only 0.5% after lobectomy. 3 A large BPF occurring as a complication in patients with adult respiratory distress syndrome (ARDS) is rare. BPF oc- curring as a complication in patients with ARDS typically appears after one to two weeks of illness, and is associated with a poor prognosis. 4 CASE PRESENTATION A 37-year-old male presented with near-drowning. Past medical history was notable for congenital brain ab- normalities and seizures. Upon emergency department (ED) arrival, his Glasgow coma scale (GCS) was found to be three, and he was intubated. Arterial blood gas (ABG), clinical findings, and chest X-ray (CXR) were consistent with ARDS. He was started on lung protective ventilation with low tidal volume (TV) strategy at 6 ml/kg predicted body weight. A few hours later, his oxygen saturations (O2 sats) dropped to 71% on FiO2 (fraction of inspired oxygen) of 100%. Mode of ventilation was changed to assisted pres- sure control ventilation with inspiratory pressure of 18 cm of H2O and positive end expiratory pressure (PEEP) of 15 cm of H2O. But due to inadequate ventilation, he was then switched back to assisted volume control ventilation with lowTV and high PEEP of 20 cmof H2O, leading to improved oxygenation. His plateau pressures were measured to be 31 cm of H2O on these settings. Patient became hypotensive and a right internal jugular (RIJ) central line was placed for vasopressor support. RIJ placement was complicated by a large right-sided pneu- mothorax (Figure A) requiring an emergent chest tube (12 French) placement. He was subsequently admitted to the intensive care unit (ICU).
Figure A: Chest radiograph (antero-posterior view) showing large right-sided pneumothorax.
On hospital day two, due to worsening oxygenation (PaO2/FiO2 68 on FiO2 100% and PEEP 20 cm of H2O) and agitation (despite adequate sedation and analgesia), he was started on cisatracurium (for 48 hours) in view of evidence demonstrating mortality benefit with neuromus- cular blocker when used early in patients with severe ARDS. On hospital day three, a computed tomography (CT) scan of the chest showed residual right-sided pneumo- thorax, subcutaneous emphysema, and extensive bilateral air-space disease consistent with ARDS. No lung lacera- tion/BPF was noted. A large bore (28 French) chest tube
258 J La State Med Soc VOL 166 November/December 2014
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