Abstract Bronchopleural fistula (BPF) in the setting of advanced malignancy presents a profound challenge, often complicated by persistent air leak, hydropneumothorax, and empyema. The presence of multiple co-existing, life-threatening pleural and pulmonary pathology mandates a highly aggressive, multidisciplinary approach. This case details the complex and sequential management of a refractory malignant BPF complicated by trapped lung, empyema necessitans and subsequent complications. A 68-year-old male with a history of chronic hypoxic respiratory failure and stage IV squamous cell lung carcinoma developed acute shortness of breath and tachycardia during chemotherapy. Imaging revealed a necrotic lung mass with a large air-fluid level encompassing the left lower lobe, consistent with developing BPF and empyema Figure 1. Initial management included thoracentesis yielding purulent fluid, followed by pleural pigtail catheter placement. Culture of fluid grew Prevotella oris, Granulicatella adiacens, and Streptococcus anginosus. Infectious disease was consulted and patient was started on ampicillin/sulbactam. Due to continuous purulent/necrotic discharge and a persistent air leak, cardiothoracic surgery was consulted and recommended a thoracotomy with pleural biopsy, removal of the pleural pigtail catheter and placement of an indwelling pleural catheter (IPC). Following surgery, air leak persisted, but cardiothoracic surgery denied definitive surgical repair due to concurrent cancer and infection. The patient was then transferred for the placement of endobronchial valves (EBVs) to seal the BPF. After valve placement, the patient was returned to our facility and developed pneumomediastinum and diffuse subcutaneous emphysema. A second pleural pleural catheter was then placed to ensure continuous drainage, but no air leak was noted and chest tube output was minimal. Following removal of the temporary pleural pigtail catheter, the IPC was clamped, demonstrating no worsening hydropneumothorax. The patient was safely discharged home with his IPC and instructed to follow up with interventional pulmonology and our pulmonology clinic. This case illustrates the perilous cascade initiated by a malignant BPF. Despite advanced interventional strategies, including surgical IPC placement and therapeutic EBV closure, the patient suffered multiple downstream complications. In cases with such as this with complex management, a multidisciplinary team (Pulmonology, Interventional Radiology, and Cardiothoracic Surgery) is paramount to manage the rapidly evolving, frequently sequential complications of advanced malignant pleural disease. This abstract is funded by: None
Kosnik et al. (Fri,) studied this question.