Bronchopleural fistula

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Editor-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 sometimes develops following pneumectomy.

Etiology

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

Right sided surgery
Chemotherapy and radiation
Diabetes mellitus
Heavy smoking and COpD
Low nutritional status
Residual tumor at bronchial margin
Extensive lymph node dissection
Older age
Long term postoperative mechanical ventilation
Tuberculous of fungal infection

Clinical features

Symptoms can vary from acute (with in first two weeks postoperative period to subacute (>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

Empyema necessitans

Examination

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

Diagnosis

Imaging

Following features can be seen on a radiograph but are better appreciated on CT

pneumothorax
pneumomediastinum
Subcutaneous emphysema
Failure of postpneumonectomy space to fill with fluid
Air bubbles around surgical side
Fistula

Bronchoscopy

It can help in determining

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

Differential Diagnosis

Reasons for tension pneumothorax in postoperative period can be

Blocked or displaced chest tube
Tension Chylothorax
Hemothorax
Signs of empyema can be due to infection as well.

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 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.

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 Small fistula Advanced malignancies	Bronchoscopic therapies and general measures does not work for large fistulas