From Pleural to Peculiar: An Unintended Tracheal Journey
Poster #: 198
Session/Time: A
Author:
Brandon Savage, DO, BS
Mentor:
Victoria Scicluna, MD MPH
Research Type: Case Report
Abstract
INTRODUCTION:
Pneumothorax (PTX) is a common problem across emergency departments in the United States, with an estimated 20,000-40,000 cases occurring annually. PTX is often one of the complications of gunshot wounds (GSW) to the chest and typically requires chest tube placement for resolution [1]. We present a case of small-bore tube thoracostomy, which was complicated by insertion into the trachea - the first report of such in the literature.
CASE INFORMATION:
We present a 22-year-old male with chief complaint of chest pain and dyspnea three weeks following a GSW to the chest previously requiring a right thoracotomy for tractotomy and right middle lobe wedge resection on initial injury. After visualization of a large, right-sided pneumothorax without tension physiology on chest radiograph, a small-bore chest tube was placed under ultrasound guidance. Upon insertion, a continuous air leak was noted in the atrium, which did not subside. A computed tomogram of the chest was obtained and demonstrated the chest tube coursing through a post-operative consolidation in the lung parenchyma before entering the bronchus intermedius and terminating within the trachea. This tube was subsequently removed, and replaced by a surgical chest tube, which was felt to be intraparenchymal with persistent PTX and air leak on repeat imaging. Finally, a third apical chest tube was placed outside of the lung tissue. He was transferred to a nearby center for thoracic surgery to discuss definitive treatment options for bronchopleural fistula, and at the time of submission of this abstract, treatment is ongoing.
DISCUSSION:
Tube thoracostomy is a procedure in which a flexible tube is inserted into the pleural space within the chest. This procedure is most commonly performed to remove air or fluid that fills this potential space. Tube thoracostomy is typically pursued for those PTX that are recurrent, persistent, traumatic, large, under tension, or bilateral. Common complications include tube blockage, dislodgement, bleeding, infection, intercostal neuralgia, and malpositioning [2]. Malposition of the tube most often occurs within the lung parenchyma, in the lobar fissure, under the diaphragm, or subcutaneously. Malposition of tube thoracostomy means that the underlying pleural problem is not improved, but also can lead to bronchopleural fistulas which may require additional invasive interventions such as airway stents, coils, or Amplatzer devices to occlude the involved bronchus, along with VATS and pleurodesis [3]. Typically the first step in management of malposition of the tube is removal and replacement with a well-positioned chest tube for ongoing drainage. Often, the "triangle of safety" is used as a guide for chest tube placement, but may not always account for anatomic variability in a patient who has had a trauma or undergone prior surgical resections. Overreliance on standard anatomical approaches without additional scrutiny can lead to suboptimal placement as we demonstrated here.
CONCLUSION:
This is the first documented case of iatrogenic bronchopleural fistula with termination of the small-bore catheter within the trachea. Bronchopleural fistulas are a challenging clinical scenario to navigate, with outcomes depending on each individual's etiology, anatomy, and background comorbid conditions. Individualized treatment planning is recommended.
Pneumothorax (PTX) is a common problem across emergency departments in the United States, with an estimated 20,000-40,000 cases occurring annually. PTX is often one of the complications of gunshot wounds (GSW) to the chest and typically requires chest tube placement for resolution [1]. We present a case of small-bore tube thoracostomy, which was complicated by insertion into the trachea - the first report of such in the literature.
CASE INFORMATION:
We present a 22-year-old male with chief complaint of chest pain and dyspnea three weeks following a GSW to the chest previously requiring a right thoracotomy for tractotomy and right middle lobe wedge resection on initial injury. After visualization of a large, right-sided pneumothorax without tension physiology on chest radiograph, a small-bore chest tube was placed under ultrasound guidance. Upon insertion, a continuous air leak was noted in the atrium, which did not subside. A computed tomogram of the chest was obtained and demonstrated the chest tube coursing through a post-operative consolidation in the lung parenchyma before entering the bronchus intermedius and terminating within the trachea. This tube was subsequently removed, and replaced by a surgical chest tube, which was felt to be intraparenchymal with persistent PTX and air leak on repeat imaging. Finally, a third apical chest tube was placed outside of the lung tissue. He was transferred to a nearby center for thoracic surgery to discuss definitive treatment options for bronchopleural fistula, and at the time of submission of this abstract, treatment is ongoing.
DISCUSSION:
Tube thoracostomy is a procedure in which a flexible tube is inserted into the pleural space within the chest. This procedure is most commonly performed to remove air or fluid that fills this potential space. Tube thoracostomy is typically pursued for those PTX that are recurrent, persistent, traumatic, large, under tension, or bilateral. Common complications include tube blockage, dislodgement, bleeding, infection, intercostal neuralgia, and malpositioning [2]. Malposition of the tube most often occurs within the lung parenchyma, in the lobar fissure, under the diaphragm, or subcutaneously. Malposition of tube thoracostomy means that the underlying pleural problem is not improved, but also can lead to bronchopleural fistulas which may require additional invasive interventions such as airway stents, coils, or Amplatzer devices to occlude the involved bronchus, along with VATS and pleurodesis [3]. Typically the first step in management of malposition of the tube is removal and replacement with a well-positioned chest tube for ongoing drainage. Often, the "triangle of safety" is used as a guide for chest tube placement, but may not always account for anatomic variability in a patient who has had a trauma or undergone prior surgical resections. Overreliance on standard anatomical approaches without additional scrutiny can lead to suboptimal placement as we demonstrated here.
CONCLUSION:
This is the first documented case of iatrogenic bronchopleural fistula with termination of the small-bore catheter within the trachea. Bronchopleural fistulas are a challenging clinical scenario to navigate, with outcomes depending on each individual's etiology, anatomy, and background comorbid conditions. Individualized treatment planning is recommended.