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.

Exams LITFL ACEM 700

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Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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