What is the management of bronchopleural fistula (BPF)?

Management of Bronchopleural Fistula (BPF)

Initial management of BPF should prioritize control of infection with antibiotics and adequate pleural drainage, followed by a stepwise approach that escalates from conservative management to bronchoscopic interventions, and finally to surgical repair only when less invasive methods fail or when dealing with large, early postoperative fistulas. 1, 2

Initial Assessment and Stabilization

Diagnostic Confirmation

• CT chest with IV contrast is the diagnostic study of choice to confirm BPF, identify the fistulous tract, and evaluate underlying causes such as necrotizing pneumonia, abscess, or empyema 1
• Direct CT signs include visualization of a fistulous tract between bronchus and pleural space 1
• Indirect CT signs include air bubbles beneath the bronchial stump or suspected fistula site 1

Immediate Management Priorities

• Control active infection with broad-spectrum antibiotics targeting anaerobic and aerobic organisms 1, 2
• Ensure adequate drainage of the pleural space to prevent empyema progression 1, 2
• Provide nutritional support, as BPF patients often have significant metabolic demands 2

Treatment Algorithm Based on Clinical Context

Conservative Management (First-Line for Small Fistulas and High-Risk Surgical Patients)

Conservative management combining tube drainage with postural drainage is effective for empyema-complicated post-lobectomy BPFs and should be attempted before surgical intervention in stable patients. 3

• Proper chest tube drainage until disseminated pneumonia is controlled 3
• Conduct pleural lavage followed by gradual transition from tube drainage to postural drainage 3
• Chest tubes typically remain 7-114 days (mean 40 days) before removal 3
• This approach achieved fistula healing in all 13 consecutive cases in one series without mortality 3

Bronchoscopic Interventions (For Small-to-Moderate Fistulas or Non-Surgical Candidates)

Bronchoscopic techniques serve as either definitive therapy for smaller BPFs or as a bridge to surgery in high-risk patients who require clinical optimization. 4, 2, 5

Available bronchoscopic options include:

• Endobronchial valves (approved under humanitarian device exemption for prolonged air leaks) 4
• Ethanol injection via EBUS-TBNA needle for directed submucosal injection leading to fistula closure 4
• Fibrin glues, polyethylene glycol, autologous blood products, gel foam, or silver nitrate 4, 5
• Amplatzer device (originally designed for atrial septal defects) 4
• Coils and various sealants 5

Important caveat: No single bronchoscopic technique is universally applicable; therapeutic success has been variable across different methods 5

Surgical Management (For Large Fistulas or Failed Conservative/Bronchoscopic Treatment)

Surgical intervention is indicated for large BPFs, early postoperative fistulas, or when conservative management fails after 7 days without resolution of sepsis. 1

Indications for Surgery:

• Large fistulas (particularly early postoperative) 1, 4
• Persistent sepsis despite antibiotics, drainage, and fibrinolytics for >7 days 1
• Prolonged sepsis, hemoptysis, or empyema complicating the fistula 1
• BPF persisting >6 weeks with antibiotic treatment 1
• Complex empyema with significant lung pathology (peel, trapped lung) 1
• Pyopneumothorax with bronchopleural fistula 1

Surgical Options:

• Percutaneous catheter drainage (PCD) for lung abscesses with BPF achieved complete resolution in 83% of cases, with 16% complication rate including spillage, bleeding, and empyema 1
• Surgical resection (lobectomy or segmentectomy) required in approximately 10% of lung abscess cases 1
• Video-assisted thoracoscopic surgery (VATS) for early-stage disease with less postoperative pain and shorter hospital stay 1
• Open thoracotomy for advanced organized empyema where VATS has higher failure rates 1
• Open window thoracostomy for persistent complex BPF requiring staged reconstruction 6

Special Considerations

Pediatric BPF Management

• Avoid surgical intervention and chest tube placement via trocar in necrotizing pneumonia, as this increases risk of BPF 1
• Most pediatric cases resolve with medical management (antibiotics, drainage, fibrinolytics) without surgery 1
• Surgical consultation warranted if sepsis persists beyond 7 days despite optimal medical management 1

Risk Factors for BPF Development

• Right-sided pneumonectomy carries higher risk than left-sided 4
• Bi-lobectomy more likely to cause BPF than single lobectomy 4
• Post-pneumonectomy incidence: 4.4-20% with mortality 27.2-71% 4
• Post-lobectomy incidence: 0.5-1.5% 4

Complications to Monitor

• Complications of percutaneous drainage include spillage of infection, bleeding, empyema, and paradoxically, new BPF formation 1
• Secondary bacterial infection may develop during prolonged treatment 1
• Persistent radiological abnormality in an asymptomatic, well child is NOT an indication for surgery 1

Stepwise Approach Summary

1. Confirm diagnosis with CT chest with IV contrast 1
2. Initiate antibiotics and ensure adequate pleural drainage 1, 2
3. Attempt conservative management with tube/postural drainage for 7 days in stable patients 1, 3
4. Consider bronchoscopic intervention for small-moderate fistulas or high-risk surgical patients 4, 5
5. Proceed to surgical repair if conservative/bronchoscopic methods fail or for large, early postoperative fistulas 1
6. Involve thoracic surgery early in decision-making, even if surgery is not immediately planned 1