A Novel Method of Percutaneous Non-Targeted Spray Application of Fibrin Glue in a Case of Extensive Pneumocystis Jirovecii Bronchopleural Fistulae

Abstract

Dear Editor, Surgical, bronchoscopic or thoracoscopic means of treating small peripheral non-resolving bronchopleural fistula (BPF) is challenging. This communication aims to highlight the potential role of image-guided usage of fibrin as a topical spray to treat intractable BPF. A 47-year-old man was admitted with Pneumocystis jirovecii pneumonia and human immunodeficiency virus infection. He desaturated during bronchoalveolar lavage. Despite ventilatory support, he developed respiratory failure requiring extracorporeal membrane oxygenation support. Computed tomography (CT) showed bilateral cystic changes, scarring and emphysema with loculated pneumothoraces requiring chest tubes (Fig. 1A). Persistent air leak from bilateral chest tubes was seen secondary to bronchopleural fistulae. At first, bronchoscopy was performed that demonstrated air leaks in the right upper lobe apical, anterior and posterior segmental bronchi. They were successfully occluded by 5 mm, 7 mm and 5 mm Watanabe spigots (Novatech, Grasse, France), respectively, and the air leak stopped on the right side. As the left side still had significant air leak with multiple small fistulas on imaging, CT-guided targeted N-butyl-2cyanoacrylate (NBCA) glue injection was done to embolize the largest air leak. However, there was persistent leak. Meanwhile, the patient developed hospital-acquired pneumonia. Non-targeted CT-guided spray application of fibrin glue to the most severely affected area of the left lung was planned as a last resort (Fig. 1A). Under CT guidance, a length-adjusted 7F sheath was introduced into the anterior aspect of the left pleural cavity with the tip facing the area of potential air leaks (Fig. 1B). The fibrin sealant (Evicel, Ethicon, Somerville, New Jersey, USA) was loaded in its dedicated dual syringe system, with each syringe separately containing 5 ml of human clottable protein (50–90 mg/ml) and thrombin (800–1200 IU/ml). The two components were delivered simultaneously in an aerosolized fashion using a CO2 insufflation device. Post-procedure CT showed dense fibrin lining along the anterior pleural surface (Fig. 1C, D). There was a partial reduction in the air leak and pneumothorax size subsequently. Two weeks later, the procedure was repeated, this time at two sites, in the medial and lateral aspects of anterior pleura showing absence of dense fibrin lining. There was a brief episode of desaturation during CO2 insufflation. This responded to oxygen supplementation and suction through the chest drain. Post-procedure CT showed pneumomediastinum and subcutaneous neck emphysema that subsided in a few days. The air leak stopped completely on day-2 with gradual resolution of the pneumothorax (Fig. 2). Ground glass opacities developed during follow-up were attributed to re-expansion edema. The patient had no procedure-related symptoms except mild self-limiting fever that lasted for 2 days post-procedure. His chest tube was removed later. Multiple small peripheral fistulas or occult fistulas, like the case presented, are difficult to manage with conventional treatment methods. The liquid sealants are particularly useful. NBCA and fibrin glue are the most widely & Kabilan Chokkappan [email protected]