PMC9402970_01
Serial chest CT images after admission. (A-C), axial images; (D), coronal image. (A) Initial chest CT shows patchy GGOs in bilateral peripheral lungs. (B) Chest CT on day 3 (day 3 of admission) shows extensive and diffuse GGOs with patchy consolidation. (C,D) Chest CT on day 7 shows diffuse consolidations worsening from GGOs with air bronchogram in both the lungs. CT, computed tomography; GGOs, ground-glass opacities.
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F1
Chest computed tomography (CT) on admission revealed patchy ground-glass opacities in both peripheral lungs, indicative of interstitial pneumonia (Figure 1A). On day 3, the patient continued to worsen clinically with progressive ground-glass opacities observed on the follow-up chest CT (Figure 1B). The chest CT on day 7 of admission revealed extensive ground-glass opacities, and diffuse consolidation with air bronchogram showing anteroposterior gradient in both the lungs, consistent with that of ARDS (Figures 1C,D). Therefore, minimally invasive open-window thoracostomy (OWT) using a wound edge protector was performed to eliminate PALs (Figure 3C and Supplementary Figure 1A). NPWT for 28 days allowed re-expansion of the collapsed lung and enhanced wound granulation, resulting in closure of the thoracic cavity without the need for muscular flaps (Figures 3E,F and Supplementary Figures 1B-E).
Serial chest CT images after induction of the invasive mechanical ventilation. (A) Axial chest CT on day 22 shows a lung cyst formation (red arrow) at the right S8 segment. Note the segmental bronchus connecting to the lung cyst (yellow arrowheads). (B) Chest CT on day 41 shows the gradually expanded cyst with air-fluid level, and wall thickening secondary to lung suppuration (red arrow). (C) Chest CT on day 43 shows a huge right-sided pneumothorax with mediastinal shift (yellow arrowheads). Note the collapsed cyst in the right segment 8 (red arrow). (D) Chest CT on day 51 shows residual air leaks after chest tube drainage (white dotted arrow), extending massive subcutaneous emphysema, and further enlargement of other lung cysts (white arrowheads). CT, computed tomography.
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Note the air-filled cystic lesion communicating to the segmental bronchus, was suspicious of a bronchopleural fistula (BPF) (Figure 2A). The patient's clinical condition remained stable thereafter; however, consecutive chest CT scans revealed progressive increase in size and number of lung cysts with a tendency to fuse with each other (Figure 2B). Chest CT revealed a large right pneumothorax due to collapsed cysts with mediastinal shift, strongly suggestive of tension pneumothorax (Figure 2C). Air leaks had persisted despite two consecutive 20-Fr chest drain insertions (Figure 2D).
Multidisciplinary approach for persistent air leaks. (A) Chest CT on day 70 shows empyema and dense pleural thickening with air-fluid level. (B) Bronchoscope shows an endobronchial valve deployment inserted into the right B8b segment. (C) Post-minimally invasive OWT using a wound retractor (white arrows). (D) VAC system. Chest CT on day 97 (E) and 143 (F) show re-expansion of the collapsed lung parenchyma, and a repair of the chest wall after VAC therapy. CT, computed tomography; OWT, open-window thoracostomy; VAC, vacuum-assisted closure.
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Moreover, collected material from chest cavity drainage tube was purulent, and CT findings on day 70 of admission were consistent with those of empyema (Figure 3A). Leak isolation performed via sequential balloon occlusion of the segmental bronchus using a bronchoscope revealed that the main source of the PALs was located in the right B8b segment, which was confirmed by an immediate reduction in air leaks on deploying a medium-sized EWS (Novatech, La Ciotat, France), and the procedure was completed (Figure 3B). Therefore, minimally invasive open-window thoracostomy (OWT) using a wound edge protector was performed to eliminate PALs (Figure 3C and Supplementary Figure 1A). On day 90, negative-pressure wound therapy (NPWT) with a vacuum-assisted closure (VAC) device (KCI Medical Products, Winborne, Dorset, United Kingdom) was performed (Figure 3D). NPWT for 28 days allowed re-expansion of the collapsed lung and enhanced wound granulation, resulting in closure of the thoracic cavity without the need for muscular flaps (Figures 3E,F and Supplementary Figures 1B-E).
Timeline of case presentation.
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We present a timeline of the case in Figure 4.