How to manage a ventilated patient with pneumothorax and suspected bronchopleural fistula?

Management of Ventilated Patient with Pneumothorax and Suspected Bronchopleural Fistula

For a ventilated patient with pneumothorax and suspected bronchopleural fistula (BPF), immediate management should include placement of a large-bore chest tube (24F-28F), application of water seal with suction, and optimization of ventilator settings to minimize air leak while maintaining adequate oxygenation.

Initial Management

Chest Tube Management

• Insert a large-bore chest tube (24F-28F) as patients on positive-pressure ventilation with suspected bronchopleural fistula require larger tubes to manage potentially large air leaks 1
• Connect the chest tube to a water seal device with suction to help re-expand the lung 1
• Monitor the bubbling in the chest tube drainage system - excessive bubbles in the intercostal drainage (ICD) bag, as noted in this case, confirms an ongoing air leak consistent with bronchopleural fistula 1, 2

Ventilator Strategy

• Modify ventilator settings to minimize air leak across the fistula 3:
  • Decrease peak inspiratory pressure
  • Use lower tidal volumes
  • Consider reducing positive end-expiratory pressure (PEEP)
  • Decrease inspiratory time
  • Reduce respiratory rate
• Aim to maintain adequate oxygenation while minimizing barotrauma and air leak 3

Ongoing Management

Monitoring and Assessment

• Perform serial chest radiographs to assess pneumothorax resolution and lung re-expansion 1
• Continue clinical assessment including auscultation - the gurgling sound heard in this case is consistent with air moving through fluid, supporting the diagnosis of BPF 2
• Monitor for signs of clinical instability including respiratory rate, heart rate, blood pressure, and oxygen saturation 1

Management of Persistent Air Leak

• If the air leak persists beyond 4 days, consider additional interventions 1
• For patients with persistent air leaks who cannot undergo surgery, chemical pleurodesis may be considered 1
• Preferred agents for chemical pleurodesis include doxycycline (good consensus) or talc slurry (very good consensus) 1

Advanced Interventions for Refractory Cases

Bronchoscopic Management

• Consider bronchoscopic evaluation to locate the fistula and potentially place endobronchial valves (EBVs) to occlude the affected airway 4, 5
• Endobronchial valves can serve as a temporary or definitive treatment for persistent BPF in non-surgical candidates 4, 3

Surgical Options

• If conservative management fails, surgical intervention may be necessary 1
• Surgical options include thoracoscopy or limited thoracotomy with repair of the fistula, bullectomy if indicated, and pleurodesis 1, 5
• The preferred surgical approach is medical or surgical thoracoscopy (very good consensus) 1

Special Considerations

Pitfalls to Avoid

• Do not clamp the chest tube in the presence of an active air leak, especially in a ventilated patient, as this may lead to tension pneumothorax 1
• Avoid excessive PEEP which can worsen the air leak through the fistula 3
• Do not remove the chest tube prematurely - ensure complete resolution of the pneumothorax and cessation of air leak before considering removal 1

Management Challenges

• BPF in mechanically ventilated patients is associated with high morbidity and mortality and requires aggressive management 5, 3
• The zero VTE (volume of trapped expiratory air) mentioned in the case suggests a large air leak with failure to accumulate expiratory volume, confirming the severity of the BPF 3
• In refractory cases, consider lung isolation techniques or extracorporeal membrane oxygenation in appropriate candidates 3

By following this structured approach, you can effectively manage a ventilated patient with pneumothorax and suspected bronchopleural fistula while minimizing complications and optimizing outcomes.