What is the recommended suction pressure for a patient with a large bronchopleural fistula (BPF)?

Management of Suction Pressure for Large Bronchopleural Fistula

For patients with large bronchopleural fistulas, minimal to no suction pressure should initially be applied, with chest tubes connected to a water seal device without suction as the first-line approach. 1, 2

Initial Management Approach

• Connect chest tube to an underwater seal drainage system without initial suction 2
• Use appropriate chest tube size:
  • 24F to 28F standard chest tube is recommended for patients with large bronchopleural fistulas or those requiring positive-pressure ventilation 1
  • Small-bore tubes (10-14F) may be considered for less severe cases as they cause less pain 2

Suction Pressure Management Algorithm

1. Initial phase: Connect to water seal device without suction
2. If lung fails to re-expand: Apply minimal suction to the water seal device 1
3. For persistent air leak: Consider gradually increasing suction while monitoring for:
   • Air leak volume
   • Respiratory parameters
   • Patient comfort

Rationale for Minimal/No Suction

The primary concern with applying suction to a large bronchopleural fistula is that excessive negative pressure can:

• Increase air flow through the fistula
• Perpetuate the air leak
• Delay healing of the bronchial defect
• Compromise respiratory mechanics 3

Special Considerations for Mechanically Ventilated Patients

For patients requiring mechanical ventilation with a large bronchopleural fistula:

• Decrease peak inspiratory pressure
• Use lower tidal volumes
• Consider lowering PEEP
• Decrease inspiratory time
• Reduce respiratory rate
• Minimize negative intrapleural pressure 3

These adjustments help decrease airflow across the bronchopleural fistula and promote healing.

Monitoring and Adjustments

• Monitor for resolution of pneumothorax with serial chest radiographs
• Assess for ongoing air leaks
• If using suction, it should be discontinued once the lung has re-expanded 1
• After discontinuing suction, observe for 5-12 hours before repeating chest radiograph to ensure pneumothorax has not recurred 1

Advanced Management Options

For persistent large bronchopleural fistulas that fail to respond to conventional management:

• Consider bronchoscopic interventions such as Amplatzer device placement 4
• Evaluate for bronchial occlusion techniques using fibrin glue and polyglycolic acid sheets 5
• In refractory cases, consider lung isolation, independent lung ventilation, or ECMO in appropriate patients 3

Pitfalls to Avoid

• Never clamp a bubbling chest tube as this can lead to tension pneumothorax 2
• Avoid excessive suction which can perpetuate the air leak and delay healing
• Do not remove chest tubes prematurely; ensure complete resolution of air leak before removal
• Be aware that complications of chest tube placement occur in approximately 11% of cases 2

The management of large bronchopleural fistulas requires careful attention to chest tube management and suction settings to promote healing while maintaining adequate respiratory function.