Nonsurgical management of dynamic pneumatocele via endobronchial administration of fibrin sealant

A 12-year-old male was admitted to the Medical Intensive Care Unit for respiratory failure requiring temporary tracheostomy secondary to an extensive necrotizing methicillin-resistant Staphylococcus aureus pneumonia. Imaging revealed destructive bronchiectasis and multifocal lung abscesses, more advanced in the right lung. He was discharged home after 42-day hospital admission. 3.5 months after his discharge, he re-presented to the Emergency Department with a large right pneumothorax and a pneumatocele measuring 10.2 × 6.2 cm2 . He was admitted to the hospital and while his pneumothorax resolved in 2 days, the size of the pneumatocele was noted to fluctuate with different phases of respiration. A computed tomography scan of the chest demonstrated a fistula between the pneumatocele and right upper lobe bronchus. Following discussion between Pulmonary medicine and Interventional radiology, transbronchial closure of the air leak was planned. Intubation was done with a dual-lumen endotracheal tube. Bronchography was performed using a diagnostic catheter. A large air leak was noted from the anterior segment of the right upper lobe bronchus. Embolization of the fistula was performed using n-butyl cyanoacrylate (nBCA, glue) injected through a second catheter under fluoroscopic guidance. The residual pneumatocele slowly resolved over 2 months. Endobronchial embolization has been described in the literature as a treatment strategy for air leaks, largely in adult patients. Endobronchial embolization of large pneumatoceles and bronchopleural fistulas may offer an alternative treatment option with less morbidity than the classic surgical approach.