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
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
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC