2009 OPEN FORUM Abstracts
ACUTE RESPIRATORY FAILURE AND INDEPENDENT LUNG VENTILATION IN AN ADULT WITH GASTRIC BRONCHIAL FISTULA SECONDARY TO NECROTIZING ASPERGILLUS PNEUMONIA
Ernie C. Chou1, Dean R. Hess1, Alexander I. Geyer2, John C. Wain3; 1Respiratory Care Services, Massachusetts General Hospital, Boston, MA; 2Pulmonary and Critical Care, Massachusetts General Hospital, Boston, MA; 3Thoracic Surgery, Massachusetts General Hospital, Boston, MA
Introduction: Gastric bronchial fistula (GBF) is a rare and devastating disease process. We report a case of GBF secondary to necrotizing Aspergillus pneumonia. Case Summary: A 50 year-old male, with past medical history significant for B-cell acute lymphoblastic leukemia and Aspergillus pneumonia, presented to the emergency department shortly after a meal with nausea, vomiting, productive cough and acute respiratory distress. He was intubated and placed on volume-controlled continuous mandatory ventilation. After intubation, positive epigastric sounds were present with copious amounts of vomitus filling the endotracheal tube. Chest X-ray and end-tidal CO2 confirmed adequate tube position. However, inhaled VT was significantly greater than exhaled VT and air bubbles were observed emitting from the nasogastric tube. Ventilation was difficult with pH 7.15, PaCO2 61 mm Hg, PaO2 65 mm Hg on FiO2 1.0. Computed tomography revealed a communication between the left lower lobe and the fundus of the stomach (Figure). A bronchial blocker was placed into the basilar segment of the left lower lobe to reduce air leak. However, its position was difficult to maintain despite sedation and paralysis. Independent lung ventilation (ILV) was implemented because serious hemodynamic and respiratory instability occurred each time the bronchial blocker moved. The right lung was ventilated with VT 300 mL and PEEP 10 cm H2O. The left lung was ventilated with VT 200 mL and PEEP of 0 cm H2O with an air leak of 40 - 60 mL. There was a marked improvement in ventilation and oxygenation with ILV. Over the ensuing 5 days, the patient stabilized, after which a left lower lobectomy, partial gastrectomy, and prosthetic reconstruction of left hemidiaphragm were performed. His recovery was slow and he was discharged 2 months later. Pulmonary cultures were positive for Aspergillus; presumably this infection produced the fistula. Discussion: GBF is rare, with only 38 prior cases reported. The diagnosis is often difficult and requires a high index of suspicion. It is most commonly seen in patients with previous gastroesophageal surgery, subphrenic abscess, gastric ulcers, trauma, or foreign body ingestion. This case illustrates respiratory care issues encountered while caring for a patient with GBF, including the use of ILV until the patient can be stabilized for definitive surgical correction. Sponsored Research - None
Computed tomography (coronal reconstruction) showing a gastric bronchial fistula between the left lower lobe and the fundus of the stomach.