Treatment of Intractable Pneumothorax with Emphysema Using Endobronchial Watanabe Spigots
A 66-year-old male patient underwent closed thoracostomy due to a right pneumothorax at an outside hospital; however, air leakage continued for more than 30 days. He was then transferred to Gangnam Severance Hospital for further evaluation and management. A chest X-ray and CT revealed diffuse lung emphysema and bullous change of the bilateral lungs, pneumomediastinum, and subcutaneous emphysema (). PFT demonstrated a FVC of 2.24 L (60% of the normal range), a FEV1 of 0.75 L (29% of the normal range), a FEV1/FVC of 33%, and a DLCO of 8.2 mL/mmHg/min (54% of the normal range). Arterial blood gas analysis showed a pH of 7.439, PO2 of 91.8 mmHg, and PCO2 of 32.2 mmHg in room air.\nThe patient's status was thought to be unsuitable for wedge resection under general anesthesia due to poor pulmonary function. Therefore, he was treated with EWS into the apical anterior and posterior segmental bronchi under fibrobronchoscopy.\nThe EWS dislodged spontaneously on the first day after the procedure, necessitating EWS reinsertion. The EWS was successfully reinserted to the apical segmental bronchi of the right upper lobe, but the EWS could not be inserted into the posterior segmental bronchi of the right upper lobe due to mucosal bleeding and severe coughing during the bronchoscopic procedure. However, air leakage stopped 2 days after EWS reinsertion. The chest tube was removed on the 4th day after reinsertion of the EWS.\nThe patient was discharged without complications and was followed. PFT on the fifteenth day after reinsertion of the EWS demonstrated improved pulmonary function as follows: a FVC of 2.90 L (78%), a FEV1 of 1.06 L (41%), a FEV1/FVC of 37%, and a DLCO of 6.5 mL/mmHg/min (43%). There was no recurrence of pneumothorax during a follow-up period of 5 months. The patient will be on the list for lung transplantation in the near future.