SS. Kho*a (Dr), RL. Hoa (Dr), MC. Yonga (Dr), ST. Tiea (Dr)

a Division of Respiratory Medicine, Sarawak General Hospital, Kuching, Sarawak, MALAYSIA

* bzk99@hotmail.com

Background Bronchial occlusion with Endobronchial Watanabe Spigot (EWS) is a useful technique in the management of persistent air leak (PAL). However, its insertion usually requires endotracheal intubation which maybe challenging in patient with poor respiratory reserve. In this report, we describe a case of successful EWS placement assisted by bidirectional guiding device (CC-6DR-1, Olympus, Japan) with the usage of supraglottic airway (laryngeal mask airway, LMA).

Case Report 64 years old lady with refractory and relapsed multiple myeloma on thalidomide and dexamethasone presented to us with necrotizing pneumonia and pyopneumothorax. Frank pus was drained after intercoastal chest tube (ICT) insertion. However, despite two weeks of adequate intravenous antimicrobial therapy, right lung remains non-expandable with persistent air leak (Cerfolio Grade 4). CT thorax confirmed right lung necrotizing pneumonia and pyopneumothorax without obvious bronchopleural fistula. Bronchial occlusion was decided as patient was deemed high surgical and anesthetic risk in view of underlying advanced life-limiting co-morbidities. Under LMA ventilation (with i.v. midazolam and fentanyl), balloon occlusion test was performed sequentially on segmental airway of right endobronchial tree. Air leak reduced significantly to Cerfolio Grade 1 upon occlusion of anterior segment of right upper lobe (RB3). Bidirectional guiding device was then inserted through the bronchoscope’s working channel with a 6mm EWS plugged at its tip. Through the LMA and cautiously through the vocal cord, the EWS was manipulated and snugged into RB3 tightly. Post procedure, air leak ceased completely and lung expansion improved. ICT was off the following day and patient discharged home with prolonged course of oral antimicrobial. Patient remained well but succumbed to her underlying hematological malignancy two months later peacefully.

Conclusion Bronchial occlusion with EWS is a valid option for high surgical risk patient with PAL. Further studies focusing on less invasive insertion technique is highly anticipated in the future.

Disclosure of funding source(s): none