Korean J Crit Care Med.  2017 Aug;32(3):284-290. 10.4266/kjccm.2016.00185.

Successful Rescue Therapy with Pumpless Extracorporeal Carbon Dioxide Removal in a Patient with Persistent Air Leakage Due to Empyema

• Cho J
• Lee YJ
• Lee JH
• Lee CT
• Cho YJ

• KMID: 2391188
• DOI: http://doi.org/10.4266/kjccm.2016.00185

Abstract

A young metastatic lung cancer patient developed empyema due to an infection with carbapenem-resistant Acinetobacter baumannii. Hydropneumothorax was detected and managed by a tube thoracotomy. However, persistent air leakage through the chest tube was observed due to the presence of a bronchopleural fistula (BPF). As hypercapnic respiratory failure had progressed and the large air leak did not diminish by conservative management, a pumpless extracorporeal lung assist (pECLA) device was inserted. The pECLA allowed the patient to be weaned from mechanical ventilation and the BPF to heal. The present case shows the effective application of pECLA in a patient with empyema complicated with BPF and severe hypercapnic respiratory failure. pECLA enabled us to minimize airway pressure to aid in the closure of the BPF in the mechanically ventilated patient.

Keyword

bronchial fistula; empyema; hydropneumothorax; hypercapnia; pumpless extracorporeal lung assist; respiratory insufficiency

MeSH Terms

Acinetobacter baumannii
Bronchial Fistula
Carbon Dioxide*
Carbon*
Chest Tubes
Empyema*
Fistula
Humans
Hydropneumothorax
Hypercapnia
Lung
Lung Neoplasms
Respiration, Artificial
Respiratory Insufficiency
Thoracotomy
Carbon
Carbon Dioxide

Figure

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  Fig. 1. Initial chest radiography from the diagnosis of lung cancer.

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  Fig. 2. Chest radiography (A) and chest computed tomography images (B, C) from the day of admission to the intensive care unit.

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  Fig. 3. Chest radiography (A) and abdominal simple radiography (B) from the day of pumpless extracorporeal lung assist (pECLA) insertion (ICU day 4). The pECLA was connected to the left femoral artery (thin arrow) and the right femoral vein (thick arrow). ICU: intensive care unit.

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  Fig. 4. Patient respiratory parameters. Changes in (A) PaCO2 and arterial pH, (B) peak inspiratory pressure and minute ventilation (MV), and (C) PaO2 and PaO2/FiO2 following the start of the pumpless extracorporeal lung assist.

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  Fig. 5. Timetable of the use of antibiotics and important events in the patient’s hospital course. pECLA: pumpless extracorporeal lung assist; ICU: intensive care unit; BAL: bronchoalveolar lavage; CRAB: carbapenem-resistant Acinetobacter baumannii; GW: general ward.

Reference

References

1. Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005; 128:3955–65.

2. Pierson DJ, Horton CA, Bates PW. Persistent bronchopleural air leak during mechanical ventilation. A review of 39 cases. Chest. 1986; 90:321–3.

3. Bein T, Weber F, Philipp A, Prasser C, Pfeifer M, Schmid FX, et al. A new pumpless extracorporeal interventional lung assist in critical hypoxemia/hypercapnia. Crit Care Med. 2006; 34:1372–7.

4. Flörchinger B, Philipp A, Klose A, Hilker M, Kobuch R, Rupprecht L, et al. Pumpless extracorporeal lung assist: a 10-year institutional experience. Ann Thorac Surg. 2008; 86:410–7. discussion 417.

5. Jung C, Lauten A, Pfeifer R, Bahrmann P, Figulla HR, Ferrari M. Pumpless extracorporeal lung assist for the treatment of severe, refractory status asthmaticus. J Asthma. 2011; 48:111–3.

6. Petzoldt M, Braune S, Bittmann I, Kluge S. Rescue therapy with a pumpless extracorporeal lung assist device in a patient with acute interstitial lung disease and severe refractory hypercapnia. Respir Care. 2012; 57:293–7.

7. Fischer S, Hoeper MM, Bein T, Simon AR, Gottlieb J, Wisser W, et al. Interventional lung assist: a new concept of protective ventilation in bridge to lung transplantation. ASAIO J. 2008; 54:3–10.

8. Pesenti A, Rossi GP, Pelosi P, Brazzi L, Gattinoni L. Percutaneous extracorporeal CO2 removal in a patient with bullous emphysema with recurrent bilateral pneumothoraces and respiratory failure. Anesthesiology. 1990; 72:571–3.

9. Hommel M, Deja M, von Dossow V, Diemel K, Heidenhain C, Spies C, et al. Bronchial fistulae in ARDS patients: management with an extracorporeal lung assist device. Eur Respir J. 2008; 32:1652–5.

10. Bombino M, Patroniti N, Foti G, Isgrò S, Grasselli G, Pesenti A. Bronchopleural fistulae and pulmonary ossification in posttraumatic acute respiratory distress syndrome: successful treatment with extracorporeal support. ASAIO J. 2011; 57:336–40.