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Chest clinic
Images in Thorax
Endobronchial coil penetration into the pleural space
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  1. Giampietro Marchetti1,
  2. David J McCracken2,
  3. Najib M Rahman2,3
  1. 1 Divisione di Pneumologia, Spedali Civili di Brescia, Brescia, Italy
  2. 2 Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
  3. 3 Oxford Respiratory Trials Unit, Oxford University Hospitals, Oxford, UK
  1. Correspondence to Dr David J McCracken, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford OX3 7LE, UK; dmccracken04{at}qub.ac.uk

https://doi.org/10.1136/thoraxjnl-2018-211754

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    Case

    A patient with severe emphysema, post pulmonary rehabilitation and on full inhaled treatment underwent elective placement of eight endobronchial coils (RePneu Lung Volume Reduction Coils) in the right lung to attempt endoscopic lung volume reduction, targeted at the upper and lower lobes. The patient was not suitable for surgical open lung volume reduction and was unable to undergo valve treatment due to homogenous disease and an incomplete fissure on thoracic CT. Twelve hours post endobronchial treatment, the patient experienced chest pain and respiratory distress, and a large right pneumothorax was demonstrated on chest radiograph. The patient required immediate chest tube insertion, and chest radiographs pre chest tube insertion and post chest tube insertion demonstrated a coil visible in the right costophrenic angle adjacent to the collapsed lung (figure 1A,B), which had entirely migrated into the pleural space. Thoracic CT confirmed the pleural coil position (figure 2A). As thoracic surgery was not feasible due to anaesthetic risk, medical thoracoscopy was undertaken under local anaesthetic and sedation. The coil was identified in the pleural space (figure 2B) and successfully removed (online supplementary video 1). The pneumothorax resolved over 48 hours of chest tube drainage post thoracoscopy, and the patient was discharged.

    Supplementary file 1

    Although pneumothorax is a known complication of coil insertion, occurring in 9.7% of cases,1 the usual mechanism is thought to be expansion of the non-treated lobe resulting in visceral tear and leak. Coil migration to cause visceral tear2 and incomplete migration have been reported,3 but to our knowledge, this is the first report identifying complete migration into the pleural space and coil rescue via medical thoracoscopy.

    Figure 1
    Figure 1

    (A) Post procedure large pneumothorax with the coil visible (arrow) in the pleural space. (B) The coil in situ (arrow) post lung expansion after chest tube insertion.

    Figure 2
    Figure 2

    (A) The coil (arrow) visible in the pleural space within pneumothorax. (B) The thoracoscopic view (D, diaphragm, L, lung, P, parietal pleural surface) with the coil in the pleural space (arrow) with a small haemothorax.

    References

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      . Effect of endobronchial coils vs usual care on exercise tolerance in patients with severe emphysema: the renew randomized clinical trial. JAMA 2016;315:2178–89.doi:10.1001/jama.2016.6261
      OpenUrl
    2. ↵
      2. Mongelli F ,
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      4. Di Giuseppe M , et al
      . Late onset of pneumothorax after bronchoscopic lung volume reduction due to migration of a nitinol coil. Eur J Cardiothorac Surg 2017.doi:10.1093/ejcts/ezx402
    3. ↵
      2. Metin B ,
      3. Yıldırım S
      . Removal of the coil applied by bronchoscopy for emphysema treatment by means of thoracoscopy. J Ann Eu Med 2016;4(Suppl 1):10–12.
      OpenUrl

    Footnotes

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.