Bronchoscopic blood patch for treatment of persistent alveolar-pleural fistula

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.