[Clinical investigation of detecting the bronchi responsible for pulmonary air leakage by injecting methylene blue saline in 27 cases with intractable pneumothorax and bronchial fistula].

OBJECTIVE: To establish a new method for detecting the bronchus responsible for pulmonary air leakage by injecting methylene blue saline and to evaluate its efficacy and safety in cases with intractable pneumothorax and bronchial fistula.

METHODS: From January 2006 to October 2013, a total of 19 cases of intractable spontaneous pneumothorax and 8 cases of bronchial fistula were recruited in the study at the Fourth Hospital affiliated to Hebei Medical University. Of all the cases, 15 were diagnosed as having tension pneumothorax and 12 as having communicating pneumothorax. All the cases failed to respond to continuous pleural suction for more than 5 days and consented to the proposed treatment. Before procedure, chest suction was established to allow sustained airflow through the drainage tube while the patients breathed normally. Under direct vision through fiberoptic bronchoscope, injection catheter was inserted into the bronchoscopy channel, and methylene blue saline was slowly injected into the potentially leaking segmental or sub-segmental bronchi. When a steady decline or disappearance in the amount of methylene blue saline in the airways was observed, or methylthionine-tainted saline was detected within the chest drainage tube, the bronchus responsible for air leakage was indicated. Before blocking the target bronchus, the negative pressure level of pleural suction should be reduced or stopped, and then porcine fibrin glue or a-cyanoacrylate was used for sealing the bronchi associated with air leakage. When the air was absent from the drainage tube, and lung recruitment was indicated in the chest X-ray for 5 days, and bronchial blockade of air leakage was proved successful.

RESULTS: The bronchi responsible for air leakage were successfully located in all 27 cases, among them segmental bronchi were located in 16, subsegmental bronchi in 10, and small subsegmental bronchus in only one. Multiple adjacent segmental involvement occurred in 3, and multiple adjacent subsegmental involvement in 5 cases. The average time for locating the target bronchi was (51 ± 9) s, among them the average time for tension pneumothorax was (48 ± 15) s compared with (53 ± 16) s for communicating pneumothorax (t = 0.416, P = 0.699) . The average amount of methylene blue saline consumed for locating the target bronchi was (42 ± 23) ml. During the procedure, the membrane of the bronchi was kept intact, and the vital signs were stable. Blockade of the target bronchi was successful with fibrin glue in 20 cases and with OB glue in 7 cases. A total of 61 times of bronchial blocking were performed, and the airflow of the chest drainage tube was instantly stopped in 17 times, gradually stopped in 10, steadily reduced in 22 and no change in 12 times. Adverse effects included severe cough in 4 cases, fever in 3, pleural hemorrhage in 3, and chest pain, atelectasis, and pneumonia in 2 cases, respectively.

CONCLUSION: The bronchi responsible for pulmonary air leakage in patients with spontaneous pneumothorax and bronchial fistula could be determined by injecting methylene blue saline into the airways. This novel method does not require special instruments, and is easy to perform with a high safety and effectiveness.