|LETTER TO EDITOR
|Year : 2019 | Volume
| Issue : 3 | Page : 270-271
Hydropneumothorax following diagnostic bronchoalveolar lavage: A rarest of rare complication
Laboni Sarkar, Sagnik Biswas, Animesh Ray, Sanjeev Sinha
Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||24-Apr-2019|
Dr. Animesh Ray
Department of Medicine, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sarkar L, Biswas S, Ray A, Sinha S. Hydropneumothorax following diagnostic bronchoalveolar lavage: A rarest of rare complication. Lung India 2019;36:270-1
|How to cite this URL:|
Sarkar L, Biswas S, Ray A, Sinha S. Hydropneumothorax following diagnostic bronchoalveolar lavage: A rarest of rare complication. Lung India [serial online] 2019 [cited 2020 May 25];36:270-1. Available from: http://www.lungindia.com/text.asp?2019/36/3/270/256929
A 55-year-old female patient, a known diabetic on oral hypoglycemic agents for the past 2½ years with a history of pulmonary tuberculosis on antitubercular therapy for the last 6 months, presented to our institute complaining of low-grade fever with evening rise of temperature and dry cough with streaky hemoptysis for 15 days, associated with loss of weight and appetite. Contrast-enhanced computed tomography scan of the chest revealed consolidation of the anterior and apicoposterior segments of the left upper lobe. Suspecting persistent disease activity, a repeat bronchoscopic sampling was planned.
After taking consent, the patient underwent bronchoalveolar lavage (BAL) following standard institutional protocol. A volume of 60 ml of normal saline was instilled after wedging the scope in the apicoposterior segment of the left upper lobe. Around 30 ml of the lavage was collected by wall-mounted suction (with the pressure kept below 100 mmHg at all times). It was carried out under light sedation with continuous monitoring. She developed dyspnea, cough, and chest pain, due to which the procedure was abandoned and an urgent chest X-ray was ordered. This revealed a left-sided hydropneumothorax [Figure 1]. The patient was started on high-flow moist oxygen and kept under close monitoring. In view of persistent symptoms with significant tachypnea and hypoxemia, a decision was promptly taken to insert an intercostal chest drain (ICD) for drainage.
|Figure 1: Immediately postprocedure chest X-ray showing a large left-sided hydropneumothorax|
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Noncontrast computed tomography chest [Figure 2] was done following this which showed no evidence of lung parenchymal injury. Fluid analysis was done which was suggestive of a transudative effusion. Serial imaging showed resolution of the hydropneumothorax with adequate lung expansion, and ICD was removed on the 3rd day (post-ICD). The BAL report was negative for tuberculosis and pyogenic and fungal infections. Antitubercular therapy was stopped, and she was discharged and followed up in the outpatient department. Her symptoms did not recur, and the chest X-ray did not show radiological progression.
|Figure 2: High-resolution computed tomography chest showing a lesion in the apicoposterior segment of the left upper lobe with subcentimetric mediastinal lymph nodes. There is a left-sided hydropneumothorax with no evidence of parenchymal lung injury. Arrow points to the chink of air in the left pleural sac|
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To the best of our knowledge, hydropneumothorax following diagnostic BAL has been reported in only two cases. Hudes et al. had described hydropneumothorax following BAL in a 23-year-old female patient with severe asthma on positive-pressure ventilation. Nicholson and Mutlu described an 80-year-old woman who developed hydropneumothorax following BAL and was ultimately proved to have nontuberculous mycobacterial infection.
It has been postulated that high intra-alveolar tension during cough leading to bleb rupture and increased transpulmonary pressure gradient causing visceral pleural tear may result in pneumothorax. Leakage of the instilled fluid into the pleural space could explain the development of hydropneumothorax in such cases. Our patient had a bout of cough during BAL and the return of lavage was 50% of the instilled fluid – suggesting perhaps that the fluid had seeped into the pleural sac through the pleural rent, resulting in a hydropneumothorax.
In conclusion, although BAL by fiber-optic bronchoscopy is considered a safe procedure, it might be complicated very rarely by hydropneumothorax. Awareness of the possibility, close monitoring of symptoms and vitals of the patient after the procedure, and chest imaging are essential to clinch the diagnosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hudes ET, Bradley JW, Brebner J. Hydropneumothorax – An unusual complication of lung lavage. Can Anaesth Soc J 1986;33:662-5.
Nicholson TT, Mutlu GM. Pneumothorax following bronchoalveolar lavage for the diagnosis of non-tuberculous mycobacterial infection. An “atypical” complication of bronchoscopy? Arch Bronconeumol 2016;52:278-9.
[Figure 1], [Figure 2]