Outline the principles of, and strategies for management of a persisting bronchopleural fistula (BPF) in a mechanically ventilated patient.
Include in your answer the advantages and disadvantages of each strategy.
Answer and interpretation
Principles of Management:
- Adequate drainage of the fistula with an intercostal catheter of adequate size to manage a large air leak.
- May require multiple catheters, and ability to manage large flow rates.
- Minimise suction.
2. Ventilatory management
- Aim is to reduce mean airway pressure to reduce flow through fistula tract
- Low tidal volume and PEEP
- Low mandatory breath rate
- Permissive hypercapnoea
- Short inspiratory time
- Attempt to wean to spontaneous breathing mode from mandatory ventilation as soon as practicable and preferably from ventilatory support altogether
3. General measures
- Standard ICU supportive management
- Broad spectrum antibiotic cover
- Attention to nutritional requirements – patients usually catabolic
Strategies for Managing Large Leaks:
1. 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.
2. High Frequency Ventilation
- 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.
- Advantages – Definitive management strategy. May be only option to seal leak.
- Disadvantages – Patient may not be fit enough to tolerate.
4. Endobronchial Occlusion
- Advantages – Widely available, can be definitive treatment.
- Disadvantages – may be technically challenging, not feasible with multiple leaks.
5. 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.
- Advantages – may be only option to treat hypoxia.
- Disadvantages – not widely available, complex, little experience.
Examiners’ comments: Overall, candidates had poor knowledge of this topic.