Video case: Induction of a hydrothorax and retrograde methylene blue (MB) instillation to detect a bronchopleural fistula (BPF)

Background: Detecting BPF may require effort and endeavor, as routine tests are of limited value. We present a case involving a 2-step method, combining induction of a hydrothorax with retrograde instillation of MB under bronchoscopy Case report: A 67 year old man with a right lower lobe carcinoma had increasing air content in the pleural cavity following lobectomy, signs of chronic infection, and repeated flares of empyema. After 4 months, he had a large basal pneumothorax and a trapped lung. Repeated bronchoscopies revealed no sign of fistula in the bronchial stump. We planned a retrograde MB instillation via a chest tube, but air had replaced fluid in the pleural cavity. We reversed this through a 6 Fr intercostal drain, by alternate exsufflation and instillation of equal volumes of 7 dl of air and saline. The purpose was to avoid pressure strain on the visceral pleura, and to ensure that the bronchial stump was adjacent to pleural fluid. A chest film confirmed this. 25 mg of MB in 50 ml of saline were instilled through the chest tube. With the patient sitting upright during bronchoscopy, we visualized blue fluid flushing in through a small fistula hole in the stump. Conclusion: Induction of a hydrothorax can aid the performance of a retrograde MB instillation in the detection and localization of a BPF. To our knowledge, this method has not been previously published.