Correct!
4. Endobronchial valve placement
Re-exploration of the bronchial stump is not necessary as the cause of the prolonged air leak is not the result of dehiscence of the bronchus but the extensive inflammation and adhesions noted at surgery. One approach to a prolonged air leak following surgery is placement of additional thoracostomy tubes to “get ahead” of the air leak, but, more recently, placement of endobronchial valves in the airway subtending the site of bronchopleural fistula may offer a more elegant solution. Pleural space debridement would not address the issue of a prolonged post-surgical air leak and is unnecessary as enlarging pleural collections were not reported on post-operative imaging and no clinical features of pleural space infection were noted.
The patient underwent bronchoscopy. No endobronchial lesions we identified. Air leaks were noted emanating from both left upper lobe segments, so one endobronchial valve was placed within the left upper lobe (Figure 9).
Figure 9. Bronchoscopy shows placement of an endobronchial valve into the left upper lobe bronchus
Over the ensuing weeks, the post-operative air leak slowed, although a persistent pneumothorax (Figure 10) required percutaneous thoracostomy tube drainage.
Figure 10. Frontal chest radiograph (A) and axial (B) and sagittal (C ) chest CT 2 weeks following thoracotomy and 6 days following left upper lobe endobronchial valve placement show the presence of the left upper lobe valve (arrow, only faintly visible in A with a metallic focus external to the patient projected over the same area) as well as the pneumothorax (arrowheads), the latter with a loculated component posteriorly (*, C) that required additional thoracostomy tube drainage.
The endobronchial valve was removed (Figure 11) after cessation of the air leak, approximately 7 weeks following the surgery.
Figure 11. Bronchoscopic removal of the endobronchial valve following cessation of the persistent postoperative air leak.
Diagnosis: Broncholithiasis presenting as post-obstructive pneumonia treated with left lower lobe resection complicated by a prolonged air leak managed with endobronchial valve placement.
References