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Bronchopleural Fistula
Bronchopleural Fistula
Fistula
氣管肋膜廔管
Dr Grace SM Lam
ICU Friday Lecture
16th January, 2009
Bronchopleural Fistula
Communication between the bronchial tree &
pleural space
Mortality varies between 18-67%
Aetiology
Postoperative 2/3
Non-postoperative 1/3
Post-operative BPF
Most commonly follows pneumonectomy (0-
9% v 0.5% in lobectomy)
Predisposing factors:
Rt pneumonectomy (shorter Rt main bronchus &
single Rt bronchial artery)
Uncontrolled preoperative pleural /pulmonary
infection
Preoperative irradiation
Trauma
Postoperative positive pressure ventilation
Faulty closure of bronchial stump
Post-pneumonectomy CXRs
Day 2
Day 14
Day 1 Day 30
Radiographics 2006;26:1449-1468
Acute Post-pneumonectomy BPF
Day 22
Tension pneumothorax
& Pulmonary flooding
Subcutaneous or
mediastinal
Contralateral lung
emphysema
consolidation
from
transbronchial
spill
Radiographics 2006;26:1449-1468
Non-postoperative BPF
Causes:
Necrotizing pneumonia, TB, lung abscess &
empyema
ARDS
Persistent spontaneous pneumothorax
Thoracic trauma
Iatrogenic (line placement, pleural biopsy, FOB)
Irradiation & chemotherapy
Clinical Presentation
Persistent air leak >24 hours after the
development of pneumothorax
Exclude other causes of persistent air leak
An external air leak
Extra-thoracic location of side holes
Disconnections
Clinical Presentation
Acute
Sudden SOB, hypotension, coughing up of fluid
& blood
Subacute
Insidious onset with fever, wasting, minimally
productive cough
Chronic
Fibrosis of pleural space prevents mediastinal
shift
Diagnosis
Clinical
Instillation of methylene blue through stump
followed by its detection in chest tube
Inhalation of different concentrations of
oxygen and N2O followed by changes in gas
concentration in post-pneumonectomy space
CT scan to delineate the aetiology
Bronchoscopy is both diagnostic &
therapeutic
General Management
Drainage of
pneumothorax &
infected pleural space
with appropriate size
chest tube(s)
Pulmonary flooding:
Airway control &
position affected lung Flow through a tube varies
down exponentially with the radius of
the tube
Treat underlying cause,
especially infection
Maintain nutritional
status
Mechanical Ventilation
BPF offers a pathway of least resistance
(or high compliance)
Potential problems
Significant loss of tidal volume (VT)
↓ CO2 excretion
↓Utilization of inspired O2
Failure to maintain PEEP
Air flow through fistula delays healing
Inappropriate cycling of ventilator
Conventional Ventilation
Goal is to maintain adequate ventilation
& oxygenation while↓fistula flow
Minimize the pressure gradient between
airway & pleural space
Minimize mean airway pressure
Lowest effective tidal volume
Shorten inspiratory time
Least number of mechanical breaths
Limit PEEP
Discontinue /minimize suction on chest tubes
Chest 1986; 90: 321-323
Persistent Bronchopleural Air Leak During
Mechanical Ventilation. A Review of 39 Cases.
A retrospective review
center in Seattle
Consecutive patients who received mechanical
Governs lung
volume &
oxygenation
Frequency