Anderson, D.K.

Abstract A 77-year-old female with history of a right lower lobe adenocarcinoma (pT1a, pN0) underwent right lower lobectomy in August 2023, which subsequently was complicated by a bronchopleural fistula at the level of the right lower lobe bronchial stump. This led to a chronic hydropneumothorax, including a fungal empyema requiring placement of a 14-French thoracostomy tube and prolonged antimicrobial treatment over the next year. In June 2024 she underwent bronchoscopy, with application of argon plasma coagulation (APC) to cauterize the immediate area abutting the bronchopleural fistula and Gore VBX stent placement from the bronchus intermedius to the right middle lobe bronchus, bypassing the right lower lobe bronchial stump. There was no air leak immediately after that procedure and she continued with a 14-French thoracostomy tube in place for empyema drainage. Unfortunately, within the next 10 days the stent migrated requiring replacement. About a month later in July, 2024 the second stent was removed and revealed a persistent defect at the level of the bronchial stump with no apparent regression in size relative to the images captured prior to the initial bronchial stent placement. Under the expanded access pathway, a size 5 Spiration endobronchial valve was placed within the fistula in the right lower lobe bronchial stump (Figure 1). At the conclusion of the bronchoscopy procedure, a recruitment maneuver was performed while the suction on the thoracostomy tube was briefly increased to -40 cm H2O suction and no air leak was evident. The next CT chest 2 weeks later showed substantial improvement of the right hydropneumothorax. The air leak never returned and the thoracostomy tube was removed once the fluid drainage became negligible. The patient's dyspnea gradually improved and she was able to wean off supplemental oxygen. A follow-up CT chest 3 months later demonstrated a very small residual right pleural effusion with no gas component and stable positioning of the endobronchial valve. The multidisciplinary team involved in the patient's care intend to maintain the endobronchial valve in position indefinitely.