B73-52 Severe Cough and Persistent Air Leak as Diagnostic Clues to a Bronchopleural Fistula in Recurrent Empyema

Abstract Introduction Bronchopleural fistula (BPF) is a rare but serious postoperative complication of thoracic manipulation. Localization is challenging and often requires repeated imaging or bronchoscopy, delaying diagnosis and management. We present a case in which severe productive cough and persistent air leak following intrapleural tPA/DNase therapy and chest-tube flushes provided key diagnostic clues to BPF. Early recognition of these bedside findings is critical to guiding intervention and preventing deterioration. Case Presentation A 38-year-old man with polysubstance use disorder, CKD stage 3b, and recurrent pneumonias presented with two days of progressive dyspnea. He was recently discharged on oral antibiotics after treatment for pneumonia with left-sided parapneumonic effusion. On presentation, he was hypoxic, requiring BiPAP. He had a WBC of 21 × 109/L, and was intubated for worsening respiratory distress. Chest CT revealed a large left hydropneumothorax, loculated left and large right pleural effusions. Bilateral chest tubes were placed, draining 3 L of purulent fluid from the left side. Despite adequate drainage, the left lung remained trapped with persistent air leak. Cardiothoracic surgery performed left-sided video-assisted thoracoscopic (VATS) decortication, revealing a large empyema cavity with extensive rind formation and necrotic parenchyma. The right-sided tube was removed after resolution, while the left remained for two weeks due to ongoing air leak. The patient was discharged on room air after chest-tube removal. Five days later, he re-presented with worsening dyspnea and drainage from prior chest-tube sites. Repeat CT demonstrated recurrent empyema, and a new left-sided chest tube was placed. During management, he developed forceful coughing immediately after chest-tube flushes and intrapleural tPA/DNase, strongly suggesting BPF. Imaging confirmed communication between the bronchus and pleural space, with the tube tip within a parenchymal cavity Figure 1. Due to high operative risk from prior infection and surgery, lobectomy was deferred, and the air leak managed conservatively. The patient was discharged on six weeks of antibiotics with outpatient cardiothoracic and pulmonary follow-up. Discussion BPF is an uncommon but life-threatening complication of necrotizing infection, thoracic surgery, or prolonged pleural drainage. Diagnosis can be challenging, particularly when imaging findings are subtle or obscured by infection. In this case, paroxysmal cough and persistent air leak after pleural interventions provided key diagnostic insight, prompting targeted imaging that confirmed bronchopleural communication. Recognition of these dynamic findings can expedite diagnosis and prevent delays. While surgery is often definitive, conservative management may be appropriate in high-risk patients. Early detection remains essential to improving outcomes in complex cases. This abstract is funded by: None