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Journal of the New Zealand Medical Association, 10-August-2012, Vol 125 No 1359

Biological glue for persistent airleak: a case report

Paul Tan, Cindy Lee, Lutz Beckert

Abstract

We report the case of a pneumonthorax in 95-year-old man with three management issues: a wrongly placed drain despite fluoroscopic guidance; the need for a larger drain because of the size of the pneumonthorax; and the use of fresh frozen plasma (FFP) as a biological glue for an ongoing airleak.

Case report

A 95-year-old man presented initially with a right toe pain secondary to osteomyelitis and was treated in hospital with intravenous antibiotics. He developed dyspnoea whilst in hospital and a chest X-ray revealed a large right-sided pneumothorax for which he underwent a fluoroscopic insertion of a right pleurocath. He had ongoing symptoms following the pleurocath insertion and clinical assessment revealed a non-functioning tube.

A CT chest showed a malpositioned pleurocath, outside the pleural space positioned underneath the right pectoral muscle, emphysematous changes including a large right lower lobe bullae and a persistent large right pneumothorax,

Figure 1. Serial chest X-rays showing progressive improvements and subsequent resolution of the pneumothorax

A 12 Fr Rocket drain was inserted. The patient made some symptomatic improvements however the lung did not inflate fully. Because of the ongoing air leak a larger a 24 Fr drain was inserted as per the BTS guidelines.1 Despite these changes the patient had ongoing air leak and radiological unresolved pneumothorax.

On day 16 he underwent a pleurodesis with 100 ml of FFP which was instilled into his pleura via his intercostal drain. His air leak stopped within a few hours and his pneumothorax resolved both clinically and radiologically. His intercostal drain was removed on day 18, he was discharged from hospital and has not had a relapse of his pneumothorax.

Discussion

This case highlights three management aspects:

Chest drains may be inserted wrongly even when fluoroscopy is used. Ongoing clinical and radiological assessment is needed.
Although the use of small less invasive pleural catheter is recommended in the first instances some patients with large pneumonthorax occasionally need a large bore chest tube or a second chest tube inserted.
Biological glue is especially suitable for older patients (with multiple comorbidities) who may not be candidates for surgical intervention.

The current BTS guidelines suggest consideration of chemical pleurodesis if the patient is unwilling or unable to undergo surgery. The chemical agents generally used are talc or doxycycline.1 Given the problems sourcing intrapleural doxycycline and the reported adverse effects of talc, we decided on FFP as a biological glue for this patient.2

Fibrin is considered a biological glue, the substrate of which can come from plasma in the form of cryoprecipitate or fresh frozen plasma. Two small studies have shown promising outcomes of resolution and reduced recurrence of pneumothoraces in the use of biological glue in patients with persisting air leaks. Methods of instillations include directly into the pleural space via the intercostals drain or selective intrabronchial tamponade.3

Author information: Paul Tan, Advanced Trainee Respiratory Medicine; Cindy Lee, Respiratory Physician; Lutz Beckert, Respiratory Physician; Department of Respiratory Medicine, Christchurch Hospital, Christchurch

Correspondence: Lutz Beckert, Department of Respiratory Medicine, Christchurch Hospital, Christchurch 8011, New Zealand. Fax: +64 (0)3 3640914; email: Lutz.Beckert@cdhb.health.nz

References:

BTS guidelines for the management of spontaneous pneumothorax, Thorax 2003;58:ii39–ii52 doi:10.1136/thorax.58.suppl_2.ii39.
AF Matar, JG Hill, W Duncan, N, Orfanakis. Use of biological glue to control pulmonary air leaks, Thorax 1990;45:670-674 doi:10.1136/thx.45.9.670.
Rehse DH, Aye RW, Florence MG. Respiratory Failure Following Talc Pleurodesis. Am J Surg. 1999 May;177(5):437–40.