Empyema with fistula successfully treated with a comprehensive approach including bronchial blocker and embolization receiving veno-venous extracorporeal membrane oxygenation

Background: Complicated empyema accompanied by bronchopleural fistula (BPF) has high mortality. The treatment strategy for severe respiratory failure due to empyema with BPF has yet to be established. Case Presentation: A 70-year-old man was brought to our hospital and diagnosed with right empyema, BPF (at bronchi B4-10), and secondary left pneumonia. We initiated drainage followed by veno-venous extracorporeal membrane oxygenation due to the severe hypoxia. First, the patient underwent endoscopic treatment with obstructive materials (known as endobronchial Watanabe spigot [EWS]) at B8-10, and was weaned off veno-venous extracorporeal membrane oxygenation on day 7. A secondary EWS was carried out at B4-6. A combination of medical treatments (drainage, antibiotics, nutritional therapy, and rehabilitation) improved his general condition. The patient was able to leave the hospital on foot. Conclusion: A comprehensive approach could explain the success of the medical treatment. The principal components are the repeated application of EWS as damage control.