How to manage bronchopleural fistula with serious fluid accumulation?

Management of Bronchopleural Fistula with Serious Fluid Accumulation

The management of bronchopleural fistula (BPF) with serious fluid accumulation requires immediate chest tube drainage with a larger bore tube (24-28F), application of controlled suction, and consideration of surgical intervention if the air leak persists beyond 4 days. 1

Initial Management

• Insert an appropriately sized chest tube:

  • For BPF with large air leak, use a 24F to 28F standard chest tube 1
  • Place at the optimal site guided by ultrasound imaging to ensure proper drainage 1
  • Connect to a water seal device with controlled suction to evacuate fluid and air 1

• Ensure complete drainage of pleural fluid:

  • Monitor drainage volume and character 1
  • Apply graded and progressive suction until fluid output is less than 100 ml/day 1
  • Avoid clamping a bubbling chest drain as this may lead to tension pneumothorax 1

Ventilation Strategy for Mechanically Ventilated Patients

• Modify ventilator settings to minimize air leak through the fistula:
  • Decrease peak inspiratory pressure 2
  • Use lower tidal volumes 2
  • Consider reducing positive end-expiratory pressure (PEEP) 2
  • Decrease inspiratory time and respiratory rate 2
  • Minimize negative intrapleural pressure 2

Management of Persistent Air Leak

• For air leaks persisting beyond 4 days, surgical evaluation is recommended 1
• Thoracoscopy is the preferred approach for persistent BPF 1
• Chemical pleurodesis may be considered in patients who are poor surgical candidates:
  • Talc slurry (4-5g in 50ml normal saline) is an effective agent 1
  • Doxycycline or talc slurry are preferred sclerosing agents 1
  • Small bore catheters (10-14F) can be used for chemical pleurodesis 1

Advanced Management Options

• For refractory cases, consider:
  • Bronchoscopic application of sealing agents to occlude the fistula site 3, 4
  • Endobronchial valve placement in selected cases 5, 2
  • Myoplasty combined with limited thoracoplasty for definitive repair in suitable candidates 6

Monitoring and Follow-up

• Perform chest radiographs to confirm:

  • Proper chest tube placement 1
  • Resolution of pneumothorax 1
  • Lung re-expansion 1

• Monitor for resolution of air leak:

  • Discontinue suction once the air leak resolves 1
  • Repeat chest radiograph 5-12 hours after the last evidence of air leak 1
  • Remove chest tube when drainage is less than 100-150 ml/24h and air leak has resolved 1

Special Considerations

• For patients with COVID-19 or suspected infection:

  • Use full personal protective equipment as pleural procedures may generate aerosols 1
  • Procedures should be performed by trained staff to minimize duration and complications 1

• In cases of empyema with BPF:

  • Ensure adequate drainage of infected fluid 1
  • Consider intrapleural fibrinolytics in complicated cases 1
  • Early surgical consultation is recommended 1

Pitfalls to Avoid

• Never use substantial force or a trocar to insert a chest drain 1
• Never clamp a bubbling chest drain as this may lead to tension pneumothorax 1
• Avoid bilateral simultaneous pleurodesis due to risk of respiratory failure 1
• Do not delay surgical consultation for persistent air leaks beyond 4 days 1
• Avoid using corticosteroids during pleurodesis as they may reduce effectiveness 1