Professor of Pulmonary & Critical Care Southern Illinois University School of Medicine, United States
Introduction: EBUS with transbronchial needle aspiration (EBUS-TBNA) is considered safe and far less invasive than mediastinoscopy or percutaneous needle biopsy. Complications that have been reported include hemorrhages, pneumothorax, infectious complications like mediastinitis, pleuropericarditis, respiratory failure, and airway injury.
Description: A 74 yo female with a history of hypertension and gastroesophageal reflux was admitted for community-acquired pneumonia, having failed outpatient antibiotics treatment and progressive worsening of symptoms. Chest CT on admission showed extensive ground-glass opacities. A review of prior CT scans showed a background of progressive pulmonary fibrosis. After one week, the patient was upgraded to IMC unit due to increased oxygen requirements. The next day, she was emergently intubated due to acute hypoxemic respiratory failure and transferred to the ICU. A bronchoscopy with left upper lobe bronchoalveolar lavage was performed, which did not reveal any specific etiology which could explain the patient's pulmonary findings. The patient was treated with broad-spectrum antibiotics and required variable doses of vasopressors. She had a poor lung compliance. A decision was made to perform EBUS-TBNA of station 7 subcarinal lymph node. A left mainstem bronchus injury complicated this procedure - a 5-6 mm tear about 1 cm from the carina (image 1). She developed bilateral pneumothoraces and progressively worsening subcutaneous air, and bilateral chest tubes were placed (image 2). An emergent thoracotomy was done. The patient had a right-sided thoracotomy, repair of the left mainstem bronchus injury with intercostal muscle flap, and a left-sided percutaneous chest tube placement. She continued to decline despite different interventions, her family elected to proceed with comfort measures.
Discussion: Although EBUS-TBNA is considered a safe procedure with rare complications, it is necessary to consider this severe life-threatening complication. Our case report highlights this rare complication and alerts pulmonologists to the importance of early recognition, which can prevent life-threatening situations.
