A bronchocele is a dilated, mucous or pus filled bronchus proximal to an obstruction which may be intrinsic due to an inflammatory stricture, a congenital brochial atresia, an endobronchial tumor, a foreign body or due to extrinsic compression. Recurrent chest infections intractable with medical management and adequate bronchial toileting, is an accepted indication for surgical resection.
We describe the case of a young man with symptomatic bronchocele who underwent Left upper lobectomy for a left upper lobar bronchocele. This case was unique in that:
- The lobectomy was technically challenging on account of variations in normal airway anatomy and dense adhesions to apical and upper portion of (L) hemithorax.
- The left upper lobe bronchial stump was wafer thin, dilated and inflammed and sutures and staples repeatedly cut through.
- Postoperatively the patient was ventilated for 48hours with isolated single lung ventilation- (R) lung- to allow time for the bronchial stump to heal.
A 29 year old patient presented with a 6 month old history of recurrent respiratory tract infections which was intractable to medical management. His weight was 79 Kgs, height 160 cm and tracheal diameter measured on CXR was 18mm. He was diagnosed to have left upper lobe bronchocoele on computerised tomography scan of chest. Fibreoptic bronchoscopy did not reveal any atretic or narrowed segments. Patient was planned for elective thoracotomy and left upper lobectomy under general anesthesia and thoracic epidural analgesia for post operative pain relief. Double lumen tube, left sided 39 F Mallinckrodt® Broncho-Cath was inserted and position was confirmed by auscultation. Standard posterolateral thoracotomy was done through the 5th intercostal space. There were dense adhesions in apical and upper portion of chest cavity. The left upper lobe bronchus was thin, inflamed, friable and dilated. Bronchial stump sutures and staples cut through on account of being thin and was reinforced with intercostal pedicle flap. On testing the left upper lobe bronchial stump at the completion of the procedure with even 30 cm of H2O, air leak was detected. As there was a risk of further dehiscence of the stump postoperatively, with the risk of development of a large bronchopleural fistula, decision was taken to rest the bronchial stump and continue single lung ventilation in the post operative period.
Diagnosis & Treatment :
The patient was shifted to the ICU with the double lumen tube with the left lung isolated. The patient was paralysed and sedated with Atracurium infusion, fentanyl infusion, and Midazolam infusion. The patient maintained stable gas exchange with volume controlled ventilation mode to the right lung with the following settings. FiO2 40%, Tidal Volume 300 ml with a set respiratory rate of 20 / minute. P peak pressures ranged around 20-23 cm of H2O. The left lower lobe was intermittently recruited under controlled pressures of 30 cm of H2O while watching for air leak from the bronchial stump in the drain bottles.
As there was no air leak 48 hours post lobectomy on checking, the left lower lobe was recruited and the patient was weaned and extubated. Incentive spirometry and chest physiotherapy expanded the lower lobe in 24 hours and patient made an uneventful recovery and was discharged in 5 days.
Pulmonary surgical procedures remain the leading cause of a BPF3. A large central bronchopleural fistula from a bronchial stump is potentially life-threatening condition with a reported mortality rate of 18-50%4. The Left upper lobe bronchial stump in our case, after an anatomical resection, was too friable, thin and inflammed to allow a secure an airtight closure even with a muscle flap. Hence we decided to retain the DLT to isolate and rest the stump for 48 hours which is not routine practice. The DLT was used to selectively to ventilate the right lung to maintain gas exchange while the left lung was rested to promote healing of the bronchial stump. The left lower lobe which was intermittently recruited and eventually ventilated after 48 hours did not collapse after extubation. Deep sedation and paralysis was required to prevent coughing and straining and hence promoted healing of the bronchial stump site. Thus a potentially disastrous brochial stump blow-out and bronchopleural fistula was averted by the combination on adequate intraoperative anticipation (buttressing the stump with an intercostal muscle flap), postoperative single lung ventilation with tailored modifications. Independent lung ventilation is technically demanding and increases resource utilization in terms of equipment, monitoring, and skilled nursing care. With careful patient selection, it can be a useful alternative to conventional methods.
Post Treatment :
Patient was had an uneventful recovery post discharge from hospital. He was able to fly back home three weeks after discharge.
- International Journal of Medical Sciences 2012; 9 (3): 207-12. Wang Y, Dai W, Sun Y, Chu X, Yang B, Zhang M.Weimin Dai et al Congenital Bronchial Atresia: Diagnosis and Treatment.
- Medical Journal Armed Forces India 2001; 57: 68-9. Singh H, Jetley RK, Maurya V, Saini M. Endobronchial tuberculosis presenting as bronchocele.
- Journal of Critical Care 2010; 25: 47-55. Shekar K, Foot C, Fraser J, Ziegenfuss M, Hopkins P, Windsor M. Bronchopleural fistula: An update for intensivists.
- European Journal of Cardiac Surgery 2000; 17: 106-10. Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures.
A case study by : Dr. Balamurali Srinivasan, Dr. Divya Amol Chandran Mahaldar
Department of Cardio Vascular Thoracic Surgery
Manipal Hospital, Goa