(1048) Bronchoscopic Drainage of Ascites? A Tale of Puzzling Pulmonary Pathophysiology

Introduction: Since the introduction of ultrasound-guided thoracentesis, the incidence of related complications decreased significantly​. Nonetheless, an increased risk still arises, particularly in large-volume thoracentesis as well as in mechanically ventilated patients​​. We demonstrate a case of an alveolopleural fistula which was detected by aspiration of ascitic fluid through the endotracheal tube.

Description: A 64-year-old male with alcoholic cirrhosis complicated by diuretic-resistant ascites and hepatic hydrothorax presented to the intensive care unit (ICU) for a transjugular intrahepatic portosystemic shunt (TIPS) procedure. He was intubated for airway protection. Later, he was noted to have increasing oxygen requirements. Initial lung ultrasound and chest X-ray (CXR) revealed no evidence of pneumothorax. Shortly after, yellow, straw-colored fluid was noted to be emanating from the endotracheal tube and the ventilator circuit, prompting an emergent bronchoscopy, which revealed over 800mL of straw-colored fluid originating from the right bronchus intermedius, flooding the tracheobronchial tree. A pigtail catheter was then promptly placed and briskly drained over 4L of fluid. Repeat CXR then unveiled a right pneumothorax. The patient was then managed with a large bore chest tube. His course was later complicated by septic shock, which ultimately led to his untimely demise.

Discussion: This case encompasses a constellation of findings that can all be traced to an understanding of the intrathoracic pressure gradients. The patient sustained an iatrogenic alveolopleural fistula during the thoracentesis. Typically, a bronchopleural or alveolopleural fistula would demonstrate a ball-valve physiology, leading to a unidirectional flow of air into the pleural space, manifesting as a pneumothorax. However, this was not the case here due to the increased intrapleural pressures from the hepatic hydrothorax, leading to the reversal of the pressure gradients, and thus the flow of the hydrothorax from the pleura into the broncho-alveolar segments. This was further evidenced by the pneumothorax revealing itself only after the placement of a pigtail catheter, representing the restoration of the traditional pressure gradient between the tracheobronchial tree and the pleura.