COUGH RESPONSE TO INTRAPLEURAL FIBRINOLYTICS PREDICTING BRONCHOPLEURAL FISTULA

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: A 79-year-old female status post right lower lobe (RLL) resection one month prior presented with shortness of breath, cough, and fever despite antibiotic therapy. Initial chest CT revealed empyema. Curiously, each administration intrapleural fibrinolytic therapy tissue plasminogen activator (tPA) recombinant deoxyribonuclease (DNase) elicited a significant cough response which raised concern for bronchopleural fistula (BPF) initial negative bronchoscopy. Repeat bronchoscopy methylene blue confirmed BPF. CASE PRESENTATION: history Stage 1B adenocarcinoma the RLL lobectomy to hospital after being seen by outpatient oncology fevers, dyspnea, hypoxia two weeks duration. When she was given levofloxacin suspected pneumonia, but her fevers persisted. She then ER where underwent showed empyema lung field. an intact surgical stump without signs Intrapleural thrombolytic tPA DNase initiated, notably, concerning performed, in 10 mL increments, 40 mL, gush visualized, confirming The patient taken OR thoracotomy decortication. discharged on antibiotics total symptomatic resolution. DISCUSSION: BPF refers communication between pleural space bronchial tree, can be complication pulmonary resection.1,2 Patients are prone developing over 75% post-pneumonectomy empyemas occurring setting BPF.2 Algar et al found mortality rate 30.8% those pneumonectomy NSCLC.5 Given morbidity related BPF, early diagnosis treatment imperative. should evaluated diagnosis. Intra-bronchial instillation saline performed monitor bubbles at site closure. Classically, if this test were non-diagnostic, patients undergo leak test, necessitating thoracoscopy positive pressure ventilation.6 Recently, localization has been achieved retrograde into drain is visualized bronchoscopy.7,8 CONCLUSIONS: In our patient, nondiagnostic suspicion remained high due repeated fibrinolytics. We believe directly presence although sensitivity specificity such exam sign likely low, it may simple, inexpensive useful hint that raises correct clinical context. REFERENCE #1: Cerfolio RJ. incidence, etiology, prevention postresectional fistula. Semin Thorac Cardiovasc Surg. 2001;13(1):3-7. doi:10.1053/stcs.2001.22493 #2: Clark JM, Cooke DT, Brown LM. Management Complications After Lung Resection: Prolonged Air Leak Bronchopleural Fistula. Surg Clin. 2020;30(3):347-358. doi:10.1016/j.thorsurg.2020.04.008 #3: Jichen Q V., Chen G, Jiang Ding J, Gao W, C. Risk Factor Comparison Clinical Analysis Early Late Fistula Non-Small Cell Cancer Surgery. Ann 2009;88(5):1589-1593. doi:10.1016/j.athoracsur.2009.06.024 DISCLOSURES: No relevant relationships Charles Abreu, source=Web Response Tony Kamel, Hemant Shah,