조성민, 김보근, 송주연, 임윤주, 김호중

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Persistent bronchopleural fistula treated with endobronchial valve insertion: a case report

삼성서울병원 내과

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조성민, 김보근, 송주연, 임윤주, 김호중

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. The treatment of BPF varies from conservative manage- ment to aggressive surgical procedures due to the lack of established guidelines or consensus. This suggests that no optimal therapy is available; rather, the current interventions are complementary and the treatment should be individualized. The use of endobronchial valves (EBVs) is one of the suggested ther- apeutic options. Herein, we report a patient with persistent air leak due to BPF with empyema complicated by necrotizing pneumonia. Despite watchful ob- servation, repetitive procedures, and surgery, the endobronchial valve (EBV) was placed to resolve the problem. The procedure began with the instillation of indigo carmine through bronchoscopy to locate the bronchial segment leading to the fistula. When indigo carmine was injected to the left lower lobe (LLL) and upper division of the left upper lobe (LUL), only a small amount passed out through the chest tube. However, a large amount of indigo carmine was expelled to the chest tube when instilled into the lingular division of the LUL. EBV (Zephyr) was placed into the lingular division of the LUL and air leak was resolved subsequently. After removal of the chest tube, the patient was discharged. During the six months of follow-up, there were no EBV-asso- ciated complications or recurrence of air leak. To the best of our knowledge, this is the first report of successful EBV therapy in a patient with persistent BPF with empyema complicated by necrotizing pneumonia. Identification of the involved segment of the bronchus by using indigo carmine has contributed to a more precise placement of the EBV. Also, adequate drainage of the pleural space with proper antimicrobial coverage against causative bacteria played an important role in successful treatment, considering the underlying etiology of BPF. To conclude, EBVs can be an effective treatment for persistent air leak due to BPF secondary to pneumonia with parapneumonic effusion.

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Characteristics of Patients Who Started Home Mechanical Ventilation in a Tertiary Care Hospital

인제대학교 부산백병원 내과

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김병우, 김성현, 양지영, 김미영, 이영민, 이현경, 이홍열

Background/Aims: Chronic diseases that cause progressive respiratory failure, for example, chronic pulmonary disease, neuromuscular disease (NMD) were common indication for home mechanical ventilation(HMV). Furthermore, advance in critical care medicine has led to an increasing number of chron- ic critically ill patients who require HMV after surviving acute respiratory failure. We reviewed the primary indications for HMV in a tertiary care hospital.

Methods: We analyzed patients who newly started HMV from July 2018 to July 2019, retrospectively. Results: The study period included a total of 31 subjects on HMV (mean age, 67.9 ± 10.5 years; males, 54.8%). 21 of 31 patients except 10 chronic critically ill patients had chronic diseases. Among these 21 chronic diseases, the most common primary diagnoses were chronic pulmonary diseases (n=10, 47.6%) followed by NMD (n=5, 23.8%%), chest wall diseases (n=3, 14.3%), and obesity hypoventilation syndrome (n=3, 14.3%). Most patients with chronic diseases (n=18, 85.7%) had started HMV due to respiratory failure caused by acute or progressive worsening of underlying disease. Only 3 patients with chronic diseases used home ventilators for acute respiratory disease such as pneumonia (n=1) and foreign body asphyxia (n=2). Chronic critical ill patients were composed of 7 patients with severe sepsis, 2 with neurologic disease (Guillain-Barre syndrome, seizure) and 1 with diabetic ketoacidosis. 19 patients underwent tracheostomy for HMV. The most fre- quently prescribed mode was pressure support mode (n=25, 80.7%), followed by pressure-assisted/controlled mandatory ventilation (n=5, 16.1%) and synchronized intermittent ventilation (n=1, 3.2%). Conclusions: Two-third of patients requiring HMV had traditional diseases that cause progressive res- piratory failure. Chronic lung disease was the most common primary diagnoses followed by NMD. Furthermore, chronic critical ill patients also frequently used HMV.