From the Guidelines
The optimal management of patients with bronchopleural fistula (BPF) and severe air leak involves a multifaceted approach, including the application of thoracic suction, converting to larger-bore chest drain, blood patch or chemical pleurodesis, endobronchial valves, or thoracic surgery, as these treatment options may provide better clinical outcomes than ongoing chest tube drainage alone. When managing BPF with severe air leak, it is crucial to consider the various treatment options available, as outlined in the British Thoracic Society guideline for pleural disease 1. The key considerations include:
- Application of thoracic suction to evacuate air and allow lung re-expansion
- Converting to larger-bore chest drain to improve drainage
- Blood patch or chemical pleurodesis to promote lung adhesion and prevent further air leak
- Endobronchial valves to occlude the air leak
- Thoracic surgery as a last resort for persistent leaks despite conservative management It is essential to tailor the management strategy to the patient's specific condition, with the goal of resolving the air leak while minimizing complications and supporting respiratory function until healing occurs, as suggested by the guideline 1. Some of the critical factors to consider when choosing a treatment option include the severity of the air leak, the patient's overall health status, and the presence of any underlying lung disease. In general, a stepwise approach may be employed, starting with less invasive options and progressing to more invasive procedures as needed, with the ultimate goal of achieving resolution of the air leak and improving the patient's quality of life, as implied by the guideline 1.
From the Research
Management of Bronchopleural Fistula (BPF) with Severe Air Leak
To manage BPF with severe air leak, several strategies can be employed:
- Decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure to decrease airflow across the bronchopleural fistula 2
- Individualizing mechanical ventilation and intrapleural catheter management to reduce air leak 2
- Considering lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in refractory cases 2, 3, 4
- Using definitive management with advanced bronchoscopic placement of valves or occlusion devices in appropriate patients 2
Ventilator Strategies
Ventilator strategies for managing BPF with severe air leak include:
- Using lung-protective tidal volumes 3, 4
- Reducing FiO2 to achieve a goal of less than 60% after intubation 3
- Considering airway pressure release ventilation, continuous neuromuscular blockade, inhaled nitric oxide, and extracorporeal membrane oxygenation as rescue therapies 3, 4, 5
- Personalizing mechanical ventilation parameters to minimize ventilator-induced lung injury (VILI) 6
Adjunctive Therapies
Adjunctive therapies that may be used to manage BPF with severe air leak include: