A tale of two passages of air leaks in a single patient with lung carcinoma posing a challenge during mechanical ventilation

Abstract

Lung carcinoma may erode into different adjacent structures and cause various local complications, including the formation of fistulas. A middle-aged male with a history of fever, cough with hemoptysis, and progressive dyspnea was found to have right upper lobe non-small cell carcinoma of the lung. Subsequently, he developed right pyopneumothorax and persistent air leak suggestive of bronchopleural fistula and suffered hypoxic cardiac arrest. Postintubation and return of spontaneous circulation, the patient started exhibiting persisted air leak from oral cavity, which made ventilation difficult along with leak via chest drain. An ulcer around the upper esophagus necessitated a computed tomography scan, which revealed two trachea-esophageal fistulas. Left-sided one-lung ventilation was employed, which improved ventilation, but the patient succumbed to the underlying disease process and septic shock. On the background of lung carcinoma and a known leaking process, a source of a second leak can often be missed. Positive pressure ventilation can be a daunting task in the presence of two concomitant leaking processes. Thus, it is imperative for an intensivist to have a high index of suspicion to detect such occurrence in a patient with lung carcinoma.

Keywords

• bronchopleural fistula
• carcinoma
• lung cancer
• mechanical ventilation
• non-small cell lung
• tracheoesophageal fistula
• videolaryngoscope