Bronchopleural fistula: Difference between revisions

Jump to navigation Jump to search
Line 60: Line 60:


== Natural History And Classification ==
== Natural History And Classification ==
Cough and changes in the air-fluid pattern on chest radiograph after surgery are critical as warning signs of BPF. Other manifestations include fever with serosanguinous or purulent sputum. Large fistula causing aspiration to the contralateral lung or if a tension pneumothorax can develops acute respiratory distress. Many cases are associated with empyema. The diagnosis must be suspected when there is a persistent post-operative air-leak (immediate post-operative period), or a new or increasing air-fluid level, or disappearance of pleural fluid on chest radiographs (if patient has no chest tube in place. With a delayed BPF, a new air fluid level appears in a previously opacified haemithorax. Bronchopleural fistula typically manifests seven to fifteen days following a lung resection. Bronchopleural fistula occurring postoperatively almost always occur within three months after surgery while those developing as a complication of pleuropulmonary infections may develop at any point of time during the course of illness. Varoli classified  fistulas according  to the time of onset after the operation:  
Patients with BPF can present with symptoms that range from acute symptoms to subacute symptoms. Most patients present in the first two weeks following lung resection. Bronchopleural fistula occurring postoperatively after lung resection almost always occur within three months of surgery while those developing as a complication of pleuropulmonary infections may develop at any point of time during the course of illness. BPF should be suspected in the postoperative lung resection patient who presents with sudden onset of dyspnea, chest pain, hemodynamic instability, and subcutaneous emphysema. Symptoms may be less abrupt in those who have chest tube placed. In such patients, a large persistent or new air leak through the chest tube drainage system may be the only sign.i
 
Patients who present in the late postoperative period (more than 14 days) usually  present with symptom  of empyema. These include fever, malaise, muscle wasting, cough with purulent sputum, reduced air entry and dullness to percussion on the affected side.
 
Changes in the air-fluid pattern on chest radiograph after surgery are critical as warning signs of BPF. ru Large fistula causing aspiration to the contralateral lung if a tension pneumothorax can develops acute respiratory distresrax.  Varoli classified  fistulas according  to the time of onset after the operation:  
* Early [1 to 7 days]
* Early [1 to 7 days]
* Intermediate [8 to 30 days]
* Intermediate [8 to 30 days]
Line 66: Line 70:


== Clinical features ==
== Clinical features ==
Symptoms can vary from acute (with in first two weeks postoperative period to subacute (>14 days
Symptoms can vary from acute, with in first two weeks postoperative periodto subacute ie. >14 days.


=== Acute Symptoms ===
=== Acute Symptoms ===
Line 83: Line 87:


=== Complication ===
=== Complication ===
[https://radiopaedia.org/articles/empyema-necessitans Empyema necessitans]  
Following complications can arise due to formation of Bronchopleural fistula.
* 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
* [https://radiopaedia.org/articles/empyema-necessitans Empyema necessitans]
* death


== Examination ==
== Examination ==
Line 89: Line 100:
* Examine the patient (an ABC based primary survey, ensuring that the patient is not about to die of pneumothorax or mediastinal shift and is vitally stable)
* Examine the patient (an ABC based primary survey, ensuring that the patient is not about to die of pneumothorax or mediastinal shift and is vitally stable)
* Exclude drain dislodgement (examine the drain)
* Exclude drain dislodgement (examine the drain)
*
* Quantify the leak by asking the patient to follow below given instructions.
* Quantify the leak by asking the patient to follow below given instructions.
** Ask the patient to cough
** Ask the patient to cough
Line 102: Line 112:


== Diagnosis ==
== Diagnosis ==
The diagnosis must be suspected in a postoperative lung resection patient when there is a
* persistent air-leak (immediate post-operative period)
* a new or increasing air-fluid level
* disappearance of pleural fluid on chest radiograph, if patient has no chest tube in place.
With a delayed BPF, a new air fluid level appears in a previously opacified haemithorax.


=== Imaging ===
=== Imaging ===
Following features can be seen on a radiograph but are better appreciated on CT
Radiological features and CT scan that suggest the presence or the development of a BPF. Following features can be seen on a radiograph but are better appreciated on CT which hints towards formation of BPF
* Increase in intrapleural air space
* Appearance of a new air fluid level
* Changes in an already present air fluid level
* Drop in air fluid level exceeding 2 cm
* Cavity mass in case of malignancy
* [[pneumothorax]]
* [[pneumothorax]]
* [[pneumomediastinum]]
* [[pneumomediastinum]]
Line 113: Line 133:


=== Bronchoscopy ===
=== Bronchoscopy ===
It can help in determining
The presence of BPF is suggested by the return of continuous bubbles during bronchial washing. A bronchoscope with inflation of a balloon-tipped catheter into selected airways can aid in localization, as balloon occlusion decreases or eliminates an air. Small metallic probes introduced through the working channel of the bronchoscope, and changes in gas concentration in the pneumonectomy cavity after inhaling different concentrations of oxygen and N2O are also useful. It can help in determining
* proper evaluation of stump
* Surgical site
* Surgical site
* Fistula size and site
* Fistula size and site
Line 119: Line 140:
* Localization of fistula by instilling dye
* Localization of fistula by instilling dye
* Rule out other etiologies
* Rule out other etiologies
While a large BPF is more likely to be seen on bronchoscopy, sequential balloon occlusion of the bronchi is sometimes used, particularly for the localization of a smaller or segmental BPF.
=== CT Bronchography ===
Computed tomography bronchography (CTB) has been used to diagnose difficult BPF. 20 to 30 mL of a water-based nonionic low osmolar iodinated contrast medium iois injected hexol at the suspected fistula site following bronchoscopy either through a catheter or directly through the working channel of the bronchoscope . The fistula was easily visualized using standard axial and sagittal se on CT.
=== Capnography ===
Capnography can be used to identify the bronchial segment related to BPF. End-tidal carbon dioxide is measured by connecting a capnograph to a polyethylene catheter and has a reported a sensitivity of 83% and a specificity of 100% in the diagnosis of BPF.<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/books/NBK534765/|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>
=== Pulsography ===
Endoscopic monitoring of pulse blood flow in the bronchial stump after pneumonectomy is a reliable method of prediction of the BPF with the probability of 77.2% It is one of the latest modality in diagnosing  BPF. <ref>{{Cite web|url=https://academic.oup.com/icvts/article/23/suppl_1/i18/2487499|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>


== Differential Diagnosis ==
== Differential Diagnosis ==
Line 243: Line 274:
{| class="wikitable"
{| class="wikitable"
|+
|+
!rategyt
!Strategy
!vantaged
!Advantages
!Disadvantage
!Disadvantage
!
!
Line 259: Line 290:
!
!
|-
|-
!onchial Stentingr
!Bronchial Stenting
!
!
* The affected bronchus can be stented over bronchoscopically, thereby blocking the leak.
* The affected bronchus can be stented over bronchoscopically, thereby blocking the leak.
* This is a minimally invasive alternative to surgical patch repair
* This is a minimally invasive alternative to surgical patch repair
!
!
* You need to be sure of where the leak is
* Site of leak should be known
* The leak must be in an accessible bronchus.
* The leak must be in an accessible bronchus.
* This may not work if there are multiple leaks
* This may not work if there are multiple leaks
Line 271: Line 302:
!
!
|-
|-
!onchial Occlusionr
!Bronchial Occlusion
!Similarly to surgery, the affected pronchus is blocked with either a one-way valve or a plug. In fact, the Lois article lists options such as blood clot, cyanoacrylate glue, fibrin, lead shot,  gel foam, calf bone, and various others.
!Similarly to surgery, the affected bronchus is blocked with either a one-way valve or a plug. Other options includes blood clot, cyanoacrylate glue, fibrin, lead shot,  gel foam, calf bone, and various others.
!
!
* You need to be sure of where the leak is
* Site of leak should be known
* The leak must be in an accessible bronchus
* The leak must be in an accessible bronchus
* A major part of the lung may be sacrificed
* A major part of the lung may be sacrificed
Line 293: Line 324:
* May reduce peak pressures
* May reduce peak pressures
* Certainly reduces tidal volume (to ~50ml)
* Certainly reduces tidal volume (to ~50ml)
* Thus, theoretically reduces flow across the BPD, allowing it to heal
* Theoretically reduces flow across the BPD, allowing it to heal
|
|
* This is avery unnatural form of ventilation, and may be poorly tolerated
* This is a very unnatural form of ventilation, and may be poorly tolerated
* Large amounts of sedation or paralysis will be required
* Large amounts of sedation or paralysis will be required
|
|
|-
|-
|MOC
|ECMO
|
|
* This may be the only option for severely hypoxic patients
* This may be the only option for severely hypoxic patients

Revision as of 07:44, 21 December 2018

WikiDoc Resources for Bronchopleural fistula

Articles

Most recent articles on Bronchopleural fistula

Most cited articles on Bronchopleural fistula

Review articles on Bronchopleural fistula

Articles on Bronchopleural fistula in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Bronchopleural fistula

Images of Bronchopleural fistula

Photos of Bronchopleural fistula

Podcasts & MP3s on Bronchopleural fistula

Videos on Bronchopleural fistula

Evidence Based Medicine

Cochrane Collaboration on Bronchopleural fistula

Bandolier on Bronchopleural fistula

TRIP on Bronchopleural fistula

Clinical Trials

Ongoing Trials on Bronchopleural fistula at Clinical Trials.gov

Trial results on Bronchopleural fistula

Clinical Trials on Bronchopleural fistula at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Bronchopleural fistula

NICE Guidance on Bronchopleural fistula

NHS PRODIGY Guidance

FDA on Bronchopleural fistula

CDC on Bronchopleural fistula

Books

Books on Bronchopleural fistula

News

Bronchopleural fistula in the news

Be alerted to news on Bronchopleural fistula

News trends on Bronchopleural fistula

Commentary

Blogs on Bronchopleural fistula

Definitions

Definitions of Bronchopleural fistula

Patient Resources / Community

Patient resources on Bronchopleural fistula

Discussion groups on Bronchopleural fistula

Patient Handouts on Bronchopleural fistula

Directions to Hospitals Treating Bronchopleural fistula

Risk calculators and risk factors for Bronchopleural fistula

Healthcare Provider Resources

Symptoms of Bronchopleural fistula

Causes & Risk Factors for Bronchopleural fistula

Diagnostic studies for Bronchopleural fistula

Treatment of Bronchopleural fistula

Continuing Medical Education (CME)

CME Programs on Bronchopleural fistula

International

Bronchopleural fistula en Espanol

Bronchopleural fistula en Francais

Business

Bronchopleural fistula in the Marketplace

Patents on Bronchopleural fistula

Experimental / Informatics

List of terms related to Bronchopleural fistula

pEditor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

A bronchopleural fistula (BPF) is a fistula between the pleural space and the bronchial tree. It is a sinus tract between the bronchus and the pleural space that may result from many reasons but most commonly following pneumectomy, or sometimes due to tumors at bronchial margin. It can also occur in response to chemotherapy, radiotherapy COpD, lymph node dissection, long term mechanical ventilation and infections. On imaging, the diagnosis is suspected indirectly on radiograph. Increased gas in the pneumonectomy operative bed, or new gas within a loculated effusion are highly suggestive of the diagnosis. Although radiograph can help in diagnosing it but CT gives a better picture.

It can present with acute or subacute symptoms. It presents with symptoms such as sudden onset dyspnea, chest pain, hemodynamic instability in acute setting. The subacute presentation shows up with emphysema, fever, malaise. Depending on how the patient presents, general suppprtive care and surgical repair are the treatment options.

Pathophysiology

Bronchopleural fistula can occur due to necrotising pneumonia/empyema (anaerobic, pyogenic, tuberculous, and fungal), lung neoplasms, blunt and penetrating lung injuries. It can also occur as a complication of procedures, such as  lung biopsy, chest tube drainage, thoracocentesis or may complicate radiation therapy. Most commonly it occurs as a complication of lung surgery. When the bronchial stump fails to heal, a sinus tract is formed between bronchus and pleura, which causes continuous air leak into the pleura. This failure to heal can be from improper initial closure, inadequate blood supply, infection or residual malignant tumour at the bronchial stump.

Epidemiology and Demographics

The incidence of  varies from 4.5% to 20% after pneumonectomy and 0.5% after lobectomy. Certain patient characteristics increase this incidence. preoperative radiation to the chest, destroyed or infected lung from inflammatory disease, immunocompromised or immunesuppressed host, diabetes, hypoalbuminemia, cirrhosis, steroid administration, pneumonectomy, right-sided pneumonectomy, a long bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, or reintubation after resection and surgical inexperience are the factors which may make patient more vulnerable to having BPF. The increased risk of BPF associated with right pneumonectomy is due to the need of more extensive resection required in right pneumonectomy. [1] Mortality rates varies between 18 percent to 67 percent in BPF. The most common cause of death is aspiration pneumonia and subsequent acute respiratory distress syndrome or development of tension pneumothorax.

Etiology

Bronchopleural fistula mostly develops after lung resection surgery. Some other causes of bronchopleural fistula are

  • Right sided surgery[2]
  • Chemotherapy and radiation
  • Malignancies such as
    • Lung cancer
    • Thyroid cancer
    • Esophageal cancer
    • Lymphomas[3]
  • Diabetes mellitus[4]
  • Gastrointestinal causes such as
    • Gastroesophageal reflux disease with Barrett esophagus
    • Boerhaave syndrome
    • Broncholithiasis
  • Heavy smoking and COpD[5]
  • Low nutritional status
  • Residual tumor at bronchial margin
  • Extensive lymph node dissection
  • Traumatic and iatrogenic etiologies
    • Thoracic trauma with tracheobronchial tree disruption
    • Post-surgical (eg. lobectomy or lung biopsy) - by far the most common cause.
    • Bougie intubation
    • Necrotizing lung disease
    • ARDS
    • Ventilator-induced barotrauma
    • Excessive manual ventilation
    • Central line placement
    • Complication of bronchoscopy
  • Older age
  • Long term postoperative mechanical ventilation specially following criteria predisposes patient to BPF
    • High suction of the ICC
    • High tidal volumes
    • High inspiratory pressures
  • Tuberculous[6] of fungal infection[7]. Other infections such as
    • Haemophilus influenzae
    • Streptococcus viridans
    • Staphylococcus aureus
    • Pseudomona aeruginosa
    • Klebsiella pneumoniae
    • Pneumococcus
    • Nonhemolytic streptococcus
    • Aspergillus
    • Histoplasma capsulatum

Natural History And Classification

Patients with BPF can present with symptoms that range from acute symptoms to subacute symptoms. Most patients present in the first two weeks following lung resection. Bronchopleural fistula occurring postoperatively after lung resection almost always occur within three months of surgery while those developing as a complication of pleuropulmonary infections may develop at any point of time during the course of illness. BPF should be suspected in the postoperative lung resection patient who presents with sudden onset of dyspnea, chest pain, hemodynamic instability, and subcutaneous emphysema. Symptoms may be less abrupt in those who have chest tube placed. In such patients, a large persistent or new air leak through the chest tube drainage system may be the only sign.i

Patients who present in the late postoperative period (more than 14 days) usually present with symptom of empyema. These include fever, malaise, muscle wasting, cough with purulent sputum, reduced air entry and dullness to percussion on the affected side.

Changes in the air-fluid pattern on chest radiograph after surgery are critical as warning signs of BPF. ru Large fistula causing aspiration to the contralateral lung if a tension pneumothorax can develops acute respiratory distresrax. Varoli classified  fistulas according  to the time of onset after the operation:

  • Early [1 to 7 days]
  • Intermediate [8 to 30 days]
  • Late  fistulas [more than 30 days]

Clinical features

Symptoms can vary from acute, with in first two weeks postoperative period, to subacute ie. >14 days.

Acute Symptoms

  • Sudden onset dyspnea
  • Chest pain
  • Hemodynamic instability
  • Subcutaneous emphysema
  • Less severe symptoms in case of chest tube (large persistent or new air leak through chest tube drainage might be the only sign

Subacute Symptoms

  • Empyema
  • Fever
  • Malaise
  • Muscle wasting
  • Cough with purulent sputum

Complication

Following complications can arise due to formation of Bronchopleural fistula.

  • 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
  • Empyema necessitans
  • death

Examination

Examination plays a vital role in diagnosing bronchopleural fistula. A careful early examination can lead to early diagnosis and hence good prognosis. Examination should involve the following steps

  • Examine the patient (an ABC based primary survey, ensuring that the patient is not about to die of pneumothorax or mediastinal shift and is vitally stable)
  • Exclude drain dislodgement (examine the drain)
  • Quantify the leak by asking the patient to follow below given instructions.
    • Ask the patient to cough
    • Ask the patient to speak
    • Observe the quantity of bubbles.
    • If bubbling is constantly happening while the patient is speaking, the leak is significant.
    • If the bubbling is only present with cough and diminishes with ssutained coughing, the leak is probably small.

On auscultation, percussion and checking position of trachea, following findings might be present

  • Reduced air entry on affected side
  • Dullness to percussion of affected side
  • Tracheal deviation (if tension pneumothorax

Diagnosis

The diagnosis must be suspected in a postoperative lung resection patient when there is a

  • persistent air-leak (immediate post-operative period)
  • a new or increasing air-fluid level
  • disappearance of pleural fluid on chest radiograph, if patient has no chest tube in place.

With a delayed BPF, a new air fluid level appears in a previously opacified haemithorax.

Imaging

Radiological features and CT scan that suggest the presence or the development of a BPF. Following features can be seen on a radiograph but are better appreciated on CT which hints towards formation of BPF

  • Increase in intrapleural air space
  • Appearance of a new air fluid level
  • Changes in an already present air fluid level
  • Drop in air fluid level exceeding 2 cm
  • Cavity mass in case of malignancy
  • pneumothorax
  • pneumomediastinum
  • Subcutaneous emphysema
  • Failure of postpneumonectomy space to fill with fluid
  • Air bubbles around surgical side
  • Fistula

Bronchoscopy

The presence of BPF is suggested by the return of continuous bubbles during bronchial washing. A bronchoscope with inflation of a balloon-tipped catheter into selected airways can aid in localization, as balloon occlusion decreases or eliminates an air. Small metallic probes introduced through the working channel of the bronchoscope, and changes in gas concentration in the pneumonectomy cavity after inhaling different concentrations of oxygen and N2O are also useful. It can help in determining

  • proper evaluation of stump
  • Surgical site
  • Fistula size and site
  • Mucosal defect
  • Localization of fistula by instilling dye
  • Rule out other etiologies

While a large BPF is more likely to be seen on bronchoscopy, sequential balloon occlusion of the bronchi is sometimes used, particularly for the localization of a smaller or segmental BPF.

CT Bronchography

Computed tomography bronchography (CTB) has been used to diagnose difficult BPF. 20 to 30 mL of a water-based nonionic low osmolar iodinated contrast medium iois injected hexol at the suspected fistula site following bronchoscopy either through a catheter or directly through the working channel of the bronchoscope . The fistula was easily visualized using standard axial and sagittal se on CT.

Capnography

Capnography can be used to identify the bronchial segment related to BPF. End-tidal carbon dioxide is measured by connecting a capnograph to a polyethylene catheter and has a reported a sensitivity of 83% and a specificity of 100% in the diagnosis of BPF.[8]

Pulsography

Endoscopic monitoring of pulse blood flow in the bronchial stump after pneumonectomy is a reliable method of prediction of the BPF with the probability of 77.2% It is one of the latest modality in diagnosing BPF. [9]

Differential Diagnosis

Reasons for tension pneumothorax in postoperative period can be

Management

General Supportive Care

These measures are usually practiced when bronchopleural fistula has subacute presentation. Drainage of air from pleural space by chest tube thoracostomy. If fluid is collected, it should be sent for following labs

  • Cell count
  • pH
  • Total protein
  • LDH
  • Glucose
  • Cytology
  • Triglycerides
  • Gram Stains
  • Culture

Asses the patient for empyema[10] and treat him for it.

  • Broad spectrum intravenous antibiotics until gram stains, culture and sensitivity is available
  • Intrapleural fibrinolytic for patients with infected multi loculated effusions
  • postural drainage

Maximize nutrition

Treat other co morbidities

  • For mechanically ventilated patient, lower the level of positive pressure and selectively intubate healthy lung. Thihe advantages and disadvantages of some of the above mentioned measures are discussed bel.a.
rategyt vantagesd Disadvantages
h
  • Easy and readily available
  • Usually well tolerated
  • Does not interfere with weaning of ventilation
  • Risk of damaging more lung
  • Risk of creating larger leak
  • potentially perpetuates the fistula by negative essure suction
  • Invasive
  • Low tidal volume
  • Low PEEP
  • Low inspiratory rate
  • Short inspiratory time
  • Tolerate high PCO2
  • Wean rapidly
  • Extubate early
  • easy and readily available
  • Usually well tolerated
  • Early extubation is the ideal step to aim for, as spontaneous negative pressure breathing is better for BPF healing than positive pressure ventilation
  • The BPF itself may frustrate weaning off ventilation
  • Mandatory mode may prolong ventilation time
  • Permissive hypercapnea may lead to respiratory acidosis, which is not ideal for the patient with traumatic brain injury
Independent Lung Ventilation
  • Dual-lumen tube
  • Bronch blocker
  • Isolation of one lung permits the selective low-volume low-pressure ventilation of the affected lung, and more rapid higher volume ventilation of the unaffected lung.
  • PCO2 levels may be easier to control in this manner
  • Technically difficult: DLT insertion is one thing; running two ventilators is another.
  • There may be leak of gas and pressure from one lung to another if the seal is imperfect
  • Sedation requirements will  be higher, to tolerate the larger tube and the very unnatural respiratory pattern
  • Local pressure effects of the DLT are also more problematic

Surgical Repair

Surgical repair is usually done in patients if symptoms of bronchopleural effusion arise after lung resection.

patient procedure Indication Contraindication
Acute symptoms
  • Stump debridement and closure
  • VATS
  • Thoracotomy
  • Fit for surgery
  • Healthy bronchial stump
  • Expected exyubation
Wait until extubation in patients with
  • Hemodynamic instability
  • Hypoxia
Subacute symptoms Time to bridge period before surgery by
  • Bronchoscopic Therapies
  • General measures
  • Empyema
  • poor nutrition status
  • poor physical strength[11]
  • Small fistula
  • Advanced malignancies
Bronchoscopic therapies and general measures does not work for large fistulas

Bronchoscopic therapies are performed depending on size of the fistula. Advantages and disadvantages of some of the invasive strategies have been given below.

Strategy Advantages Disadvantage
Surgical Repair
  • Success rates are between 80 and 95%
  • It may be impossible to find the leak intraoperatively
  • It may be unfeasible to remove so much lung
  • It may be impossible if there are multiple leaks
  • The patient must tolerate one-lung ventilation
  • This approach requires thoracotomy
Bronchial Stenting
  • The affected bronchus can be stented over bronchoscopically, thereby blocking the leak.
  • This is a minimally invasive alternative to surgical patch repair
  • Site of leak should be known
  • The leak must be in an accessible bronchus.
  • This may not work if there are multiple leaks
  • The procedure requires technical expertise
  • The patient must be fit to tolerate the bronchoscopy
Bronchial Occlusion Similarly to surgery, the affected bronchus is blocked with either a one-way valve or a plug. Other options includes blood clot, cyanoacrylate glue, fibrin, lead shot,  gel foam, calf bone, and various others.
  • Site of leak should be known
  • The leak must be in an accessible bronchus
  • A major part of the lung may be sacrificed
  • The atelectatic lung may develop infection
Application Of PEEP to ICC
  • The equal intra and extrathoracic PEEP decreases the leak volume
  • Maintained intra-thoracic PEEP permits higher PEEP levels to be used
  • Drainage is compromised
  • There is a major risk of rapid tension pneumothorax
OVF
  • May reduce peak pressures
  • Certainly reduces tidal volume (to ~50ml)
  • Theoretically reduces flow across the BPD, allowing it to heal
  • This is a very unnatural form of ventilation, and may be poorly tolerated
  • Large amounts of sedation or paralysis will be required
ECMO
  • This may be the only option for severely hypoxic patients
  • With ECMO, one can limit or totally abolish gas flow through the BPF
  • All the risks of ECMO apply, as it is a maximally invasive therapy
  • It is not widely available.
  • There is little experience with this in BPF.

Refractory Cases

Occlusive materials can be methyl 2 cyanoacrylate, N butyl cyanoacrylate, albumin glutaraldehyde tissue adhesive, polyvinyl alcohol sponge or fibrin glue[12]. In scelrosants, endobronchial injection of ethanol, polydocanol and tetracycline is given. For small bronchopleural fistula, argon plasma coagulation and neodymium doped yttrium aluminuin garnet laser have been used. Omentum[13] can be used to repair the defect as well. Endobronchial occlusion[14] is also an option on table.

For refractory patients, following interventions could be done.

  • Repeat surgery
  • Alternate bronchoscopic mathod
  • Open window thoracostomy[15]

Follow Up

Monitor

  • Clinical symptoms of recurrence
  • Chest tube air output
  • Radiograph and CT

Bronchoscopy is done if symptoms reappear.

shown below are courtesy of Sedat Altin MD, Levent Dalar MD and Cafer Zorkun MD from Yedikule Education and Research Hospital, Istanbul - Turkey.

References

  1. https://www.ncbi.nlm.nih.gov/pubmed/11309718. Missing or empty |title= (help)
  2. https://www.ncbi.nlm.nih.gov/pubmed/29516277. Missing or empty |title= (help)
  3. https://en.wikipedia.org/wiki/Bronchopleural_fistula. Missing or empty |title= (help)
  4. https://www.ncbi.nlm.nih.gov/pubmed/27063612. Missing or empty |title= (help)
  5. https://www.ncbi.nlm.nih.gov/pubmed/27499951. Missing or empty |title= (help)
  6. https://www.ncbi.nlm.nih.gov/pubmed/29516277. Missing or empty |title= (help)
  7. https://www.ncbi.nlm.nih.gov/pubmed/25019431. Missing or empty |title= (help)
  8. https://www.ncbi.nlm.nih.gov/books/NBK534765/. Missing or empty |title= (help)
  9. https://academic.oup.com/icvts/article/23/suppl_1/i18/2487499. Missing or empty |title= (help)
  10. https://www.ncbi.nlm.nih.gov/pubmed/30054070. Missing or empty |title= (help)
  11. https://www.ncbi.nlm.nih.gov/pubmed/29348280. Missing or empty |title= (help)
  12. https://www.ncbi.nlm.nih.gov/pubmed/29109057. Missing or empty |title= (help)
  13. https://www.ncbi.nlm.nih.gov/pubmed/29587951. Missing or empty |title= (help)
  14. https://www.ncbi.nlm.nih.gov/pubmed/29443771. Missing or empty |title= (help)
  15. [https://www.ncbi.nlm.nih.gov/pubmed/23525638 https://www.ncbi.nlm.nih.gov/pubmed/26743783 https://www.ncbi.nlm.nih.gov/pubmed/27220922 https://www.ncbi.nlm.nih.gov/pubmed/29109057 https://www.ncbi.nlm.nih.gov/pubmed/23525638 https://www.ncbi.nlm.nih.gov/pubmed/26743783 https://www.ncbi.nlm.nih.gov/pubmed/27220922 https://www.ncbi.nlm.nih.gov/pubmed/29109057] Check |url= value (help). line feed character in |url= at position 45 (help); Missing or empty |title= (help)

Template:WH Template:WS