How to manage a case of bronchopleural fistula?

Management of Bronchopleural Fistula

The management of bronchopleural fistula (BPF) requires immediate intervention with chest tube placement, control of infection, and appropriate ventilatory strategies, followed by definitive repair through either surgical or bronchoscopic approaches based on fistula size and patient condition. 1

Diagnosis and Initial Assessment

• Imaging studies:

  • CT chest with IV contrast is the gold standard for detecting BPF 2
  • Direct signs: visible fistulous tract between bronchus/lung and pleural space
  • Indirect signs: air bubbles beneath bronchial stump or suspected fistula 2

• Bronchoscopy:

  • Essential for precise localization of the fistula
  • Allows assessment of fistula size and surrounding tissue condition
  • Facilitates planning for potential bronchoscopic interventions 3

Initial Management

Immediate Interventions

• Chest tube placement:

  • Place chest tube promptly to prevent tension pneumothorax 4
  • Use adequate suction device to drain infected pleural space
  • Extra care must be taken when placing chest tubes to avoid open communication with the pleural space 2
  • When placing chest tubes in ventilated patients, consider clamping the ventilator circuit before accessing the pleural cavity 2

• Infection control:

  • Obtain appropriate cultures
  • Initiate broad-spectrum antibiotics targeting likely pathogens
  • Adjust antibiotics based on culture results

Ventilatory Management

• For mechanically ventilated patients:

  • Use a 24F to 28F standard chest tube for patients with BPF with large air leak or those requiring positive-pressure ventilation 2
  • Minimize airway pressures (lower tidal volumes, PEEP)
  • Consider positioning patient with affected side down
  • If conventional ventilation fails, consider high-frequency ventilation 4

• For chest drainage systems:

  • Use water seal device with or without suction 2
  • Apply suction if the lung fails to reexpand with water seal drainage alone 2
  • In case of prolonged air-leaks, consider wall suction to create a closed system 2

Definitive Management

Surgical Approaches

• Indications for surgical repair:

  • Large fistulas
  • Failed bronchoscopic interventions
  • Healthy patients who can tolerate surgery

• Surgical options:

  • Direct closure of the fistula
  • Muscle flap transposition (e.g., pectoralis major) to obliterate empyema cavity and close the fistula 5
  • Thoracoplasty for chronic cases with large empyema cavities

Bronchoscopic Interventions

• Indications:

  • Small fistulas
  • High surgical risk patients
  • Patients with poor pulmonary function

• Techniques:

  • Bronchoscopic placement of blocking agents
  • Atrial/ventricular septal defect occluders
  • Airway stents
  • Endobronchial valves (EBVs)
  • Endobronchial Watanabe spigots (EWSs) 3
  • Application of sealing agents to occlude the fistula site 4

Monitoring and Follow-up

• Monitor for resolution of air leak
• Chest tubes should be removed in a staged manner to ensure the air leak has resolved 2
• First stage: confirm complete resolution of pneumothorax on chest radiograph and no clinical evidence of ongoing air leak
• Discontinue any suction applied to the chest tube 2
• Repeat chest radiograph 5-12 hours after the last evidence of an air leak 2
• Continue antibiotics as needed for associated infections

Special Considerations

• For persistent BPF:

  • Consider longer-term drainage options
  • Evaluate for underlying conditions preventing closure (e.g., malnutrition, infection)
  • Reassess surgical options if bronchoscopic interventions fail

• For BPF with empyema:

  • Aggressive drainage of empyema is essential
  • Consider irrigation of pleural space with antiseptic solutions
  • May require open window thoracostomy (Eloesser flap) in severe cases

Pitfalls and Caveats

• Delayed diagnosis and treatment significantly increase mortality
• Inadequate drainage of associated empyema leads to persistent infection
• Excessive ventilatory pressures can worsen air leak
• Multiple failed interventions increase risk of complications
• Nutritional status must be optimized to promote healing
• Underlying pulmonary disease may complicate management and worsen outcomes

The successful management of BPF requires a treatment strategy tailored to individual patient needs, with the primary goals of controlling infection, managing air leak, and achieving definitive closure of the fistula 6.