DP21: MANAGING A LARGE BRONCHOPLEURAL FISTULA AND AIR LEAK POST-ELOESSER FLAP USING DOUBLE-LUMEN TUBE FOR ONE-LUNG VENTILATION: A CASE REPORT
Kelvin Mathew, MD; Joshua Raber, MD; Christian Diaz, MD, MBA
The University of Miami/Jackson Health System
Introduction: Eloesser flaps are uncommon surgical procedures that create a permanent open drainage window into the pleural cavity for the management of chronic, complicated empyema. A rare but serious complication is the development of a bronchocutaneous fistula, which creates a direct communication between the bronchial tree and the chest wall. For anesthesiologists, these conditions present unique airway and ventilation challenges that require early recognition and careful planning.
Case Description: A 61-year-old man with a history of hypertension, chronic obstructive pulmonary disease, right lung cancer status post right upper lobectomy, and a prior Eloesser flap with failed closure resulting in a chronic bronchopleural fistula was transferred to a regional trauma center after sustaining facial burns while lighting a cigarette at home. He was on home oxygen at baseline.
The patient arrived intubated with a 7.0 mm oral endotracheal tube placed at an outside hospital. The anesthesia team was called to evaluate the airway due to low expired tidal volumes on the ventilator and absent end-tidal carbon dioxide on capnography. Examination revealed a large, chronic right chest wall defect consistent with a bronchopleural fistula, explaining the significant loss of ventilation.
After multidisciplinary discussion with the trauma and cardiothoracic surgery teams, left-sided one-lung ventilation was recommended. Initial attempts at left mainstem intubation using the existing single-lumen endotracheal tube under flexible bronchoscope guidance were unsuccessful, likely due to inadequate tube length or cuff herniation. The airway was exchanged for an 8.0 mm endotracheal tube, but effective one-lung ventilation could still not be achieved.
A decision was then made to place a left-sided double-lumen endotracheal tube. A 39 French double-lumen tube was placed using direct laryngoscopy with a Macintosh 3 blade, with a grade I view and on the first attempt. Correct placement was confirmed with auscultation, capnography, and flexible bronchoscopy. One-lung ventilation was successfully established via the bronchial lumen. The patient remained hemodynamically stable with adequate oxygenation throughout the procedure.
Discussion: This case highlights the importance of early recognition of a bronchocutaneous fistula as a cause of severe ventilation failure, even when limited historical information is available. Airway management in patients with an Eloesser flap complicated by a bronchopleural fistula requires flexibility and a clear backup strategy. While an initial attempt with a single-lumen endotracheal tube was reasonable given anticipated intensive care unit needs, rapid escalation to a double-lumen tube was essential when lung isolation could not be achieved. Although prior reports describe airway management strategies for bronchocutaneous fistulas, literature addressing these challenges specifically in the setting of an Eloesser flap is limited. This case underscores the value of multidisciplinary communication and preparedness for advanced lung isolation techniques in managing complex thoracic air leaks.