CICM SAQ 2014.1 Q4
Question
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
Answer and interpretation
Principles of Management:
1. Drainage
- 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.
3. Surgery
- 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.
6. ECMO
- 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.

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Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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