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[1]
  • Chemotherapy and radiation
  • Diabetes mellitus[2]
  • Heavy smoking and COpD[3]
  • Low nutritional status
  • Residual tumor at bronchial margin
  • Extensive lymph node dissection
  • Older age
  • Long term postoperative mechanical ventilation
  • Tuberculous[4] of fungal infection[5]

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

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[6] 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[7]
  • 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.

Refractory Cases

Occlusive materials can be methyl 2 cyanoacrylate, N butyl cyanoacrylate, albumin glutaraldehyde tissue adhesive, polyvinyl alcohol sponge or fibrin glue[8]. 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[9] can be used to repair the defect as well. Endobronchial occlusion[10] is also an option on table.

For refractory patients, following interventions could be done.

  • Repeat surgery
  • Alternate bronchoscopic mathod
  • Open window thoracostomy[11]

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/29516277. Missing or empty |title= (help)
  2. https://www.ncbi.nlm.nih.gov/pubmed/27063612. Missing or empty |title= (help)
  3. https://www.ncbi.nlm.nih.gov/pubmed/27499951. Missing or empty |title= (help)
  4. https://www.ncbi.nlm.nih.gov/pubmed/29516277. Missing or empty |title= (help)
  5. https://www.ncbi.nlm.nih.gov/pubmed/25019431. Missing or empty |title= (help)
  6. https://www.ncbi.nlm.nih.gov/pubmed/30054070. Missing or empty |title= (help)
  7. https://www.ncbi.nlm.nih.gov/pubmed/29348280. Missing or empty |title= (help)
  8. https://www.ncbi.nlm.nih.gov/pubmed/29109057. Missing or empty |title= (help)
  9. https://www.ncbi.nlm.nih.gov/pubmed/29587951. Missing or empty |title= (help)
  10. https://www.ncbi.nlm.nih.gov/pubmed/29443771. Missing or empty |title= (help)
  11. [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)

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