Wiaterek Gregory, Lee Hans, Malhotra Rajiv, Shepherd Wes
Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University Medical Center, Richmond, VA 23298, USA.
J Bronchology Interv Pulmonol. 2013 Apr;20(2):171-4. doi: 10.1097/LBR.0b013e31828f4de0.
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.
尽管抗菌治疗和手术技术有所改进，但气道胸膜瘘仍然是一个重大的治疗挑战。我们报告一例56岁女性患者，因严重双侧空洞性肺炎入院，需要机械通气。患者因坏死性肺炎出现双侧气胸，导致双侧放置胸管。尽管采取了保守措施，但漏气持续存在，无法拔除胸管。进行了带有Fogarty球囊（爱德华兹公司）封堵的支气管镜检查，试图找出导致漏气的气道。通过支气管镜检查，无法封堵任何单一气道以隔离右侧瘘管。工作重点放在左侧气道，在那里可以将瘘管隔离到前内侧基底段。使用支气管镜钳将几层可吸收止血剂（通过纤维素可控氧化制备的针织织物——速即纱；强生公司）交替放置在左前内侧基底段内。通过切开的Fogarty球囊，将3毫升患者的血液注入可吸收止血剂上，形成一个封堵性血斑。手术结束时没有漏气。在机械通气期间，2天后拔除了左侧胸管，气胸未在影像学上复发。
