Bronchopleural Fistula
Reviewed and revised 28 July 2015
OVERVIEW
- Bronchopleural fistula is an unnatural communication between the bronchial tree and pleural space as evidenced by continued leak post-pneumothorax
- Bronchopleural fistulae can be life-threatening and difficult to manage
CAUSE
Underlying cause
- complication of pulmonary resection or other thoracic procedures (including ICC insertion)
- necrotic lung complicating infection
- chemotherapy or radiotherapy for lung cancer
- persistent spontaneous pneumothorax
- trauma
- tuberculosis
- complication of mechanical ventilation (e.g. in ARDS)
Perpetuating factors
- high inspiratory airway pressures
- increased mean intrathoracic pressures throughout the respiratory cycle (PEEP, inflation hold, high inspiratory-to-expiratory ratio) at increase leak
- high negative suction
CLINICAL FEATURES
- presence of cause
- persistent air leak despite placement of one or more intercostal catheters
- failure of lung to reinflate
- other signs and complications of pneumothorax and subcutaneous emphysema
COMPLICATIONS
- failure of lung re-expansion
- loss of a significant amount of each delivered TV
- loss of PEEP
- inappropriate cycling of ventilator
- inability to maintain alveolar ventilation
- death
MANAGEMENT
Resuscitation
- decompress tension pneumothorax
Conservative
- adequate sized inter costal catheter(s)
- use an adequate drainage system
Ventilation
- strategy: controlled, assist control, intermittent mandatory
- lowest possible TV
- lowest possible PEEP
- short inspiratory time
- encourage spontaneous breathing
Large leaks
- Independent Lung Ventilation
- Advantages: May minimise leak in injured lung whilst preserving gas exchange with conventional parameters in normal lung
- Disadvantages: -requires some form of double lumen tube – difficult to place and secure. May not be tolerated in hypoxic patients.
- requirement for two ventilators –either synchronous or asynchronous – technically demanding and complex.
- high frequency oscillation (controversial)
- Advantages are that it may reduce peak air pressures and theoretically reduce air leak.
- Disadvantages – not widely available. Recent evidence suggesting an increase in mortality for this ventilatory technique in ARDS patients.
- Application of PEEP to intercostal catheter
- Advantages – may decrease leak volume and maintain intra-thoracic PEEP
- Disadvantages – compromise drainage, risk of tension, not feasible with multiple tubes.
- ECMO
Invasive
- endobronchial occlusion
- Advantages – Widely available, can be definitive treatment
- Disadvantages – may be technically challenging, not feasible with multiple leaks
- bronchoscopic repair (fibrin, gelatine, cyanoacrylate-based agents, tetracycline, lead)
- surgery
- mobilization of intercostal or pectoralis muscles
- thoracoplasty
- bronchial stump stapling
- pleural abrasion and decortication
Supportive care and monitoring
References and Links
CCC Ventilation Series
Modes: Adaptive Support Ventilation (ASV), Airway Pressure Release Ventilation (APRV), High Frequency Oscillation Ventilation (HFOV), High Frequency Ventilation (HFV), Modes of ventilation, Non-Invasive Ventilation (NIV), Spontaneous breathing and mechanical ventilation
Conditions: Acute Respiratory Distress Syndrome (ARDS), ARDS Definitions, ARDS Literature Summaries, Asthma, Bronchopleural Fistula, Burns, Oxygenation and Ventilation, COPD, Haemoptysis, Improving Oxygenation in ARDS, NIV and Asthma, NIV and the Critically Ill, Ventilator Induced Lung Injury (VILI), Volutrauma
Strategies: ARDSnet Ventilation, Open lung approach, Oxygen Saturation Targets, Protective Lung Ventilation, Recruitment manoeuvres in ARDS, Sedation pauses, Selective Lung Ventilation
Adjuncts: Adjunctive Respiratory Therapies, ECMO Overview, Heliox, Neuromuscular blockade in ARDS, Prone positioning and Mechanical Ventilation
Situations: Cuff leak, Difficulty weaning, High Airway Pressures, Post-Intubation Care, Post-intubation hypoxia
Troubleshooting: Autotriggering of the ventilator, High airway and alveolar pressures / pressure alarm, Ventilator Dyssynchrony
Investigation / Indices: A-a gradient, Capnography and waveforms, Electrical Impedance Tomography, Indices that predict difficult weaning, PaO2/FiO2 Ratio (PF), Transpulmonary pressure (TPP)
Extubation: Cuff Leak Test, Extubation Assessment in ED, Extubation Assessment in ICU, NIV for weaning, Post-Extubation Stridor, Spontaneous breathing trial, Unplanned extubation, Weaning from mechanical ventilation
Core Knowledge: Basics of Mechanical Ventilation, Driving Pressure, Dynamic pressure-volume loops, flow versus time graph, flow volume loops, Indications and complications, Intrinsic PEEP (autoPEEP), Oxygen Haemoglobin Dissociation Curve, Positive End Expiratory Pressure (PEEP), Pulmonary Mechanics, Pressure Vs Time Graph, Pressure vs Volume Loop, Setting up a ventilator, Ventilator waveform analysis, Volume vs time graph
Equipment: Capnography and CO2 Detector, Heat and Moisture Exchanger (HME), Ideal helicopter ventilator, Wet Circuit
MISC: Sedation in ICU, Ventilation literature summaries
Journal articles
- Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005 Dec;128(6):3955-65. PMID: 16354867 [Free Full Text]
Critical Care
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