What is the management approach for a patient with Acute Respiratory Distress Syndrome (ARDS) and a bronchopleural fistula?

Management of ARDS with Bronchopleural Fistula

In patients with ARDS complicated by bronchopleural fistula (BPF), immediately implement ultra-low ventilator settings below standard lung-protective parameters—targeting tidal volumes as low as tolerated (often <4 mL/kg PBW), minimizing PEEP, reducing peak inspiratory pressures, and shortening inspiratory time—while considering VV-ECMO for refractory cases to facilitate fistula healing. 1, 2

Immediate Ventilator Adjustments

The primary goal is reducing air leak across the fistula by minimizing the pressure gradient driving airflow through the BPF:

• Reduce tidal volumes below standard lung-protective levels (often <4 mL/kg PBW, lower than the typical 4-8 mL/kg range) 1, 2
• Minimize PEEP to the lowest level compatible with adequate oxygenation, as higher PEEP directly increases air leak 2
• Decrease peak inspiratory pressures through pressure-limited modes and reduced driving pressures 2
• Shorten inspiratory time and reduce respiratory rate to minimize time at positive pressure 2
• Accept permissive hypercapnia if necessary to achieve these ultra-protective settings 1

Critical caveat: These ventilator adjustments directly contradict standard ARDS management recommendations for higher PEEP in moderate-to-severe ARDS 3. The presence of BPF fundamentally changes the risk-benefit calculation—preventing tension pneumothorax and promoting fistula closure takes precedence over optimizing oxygenation through conventional ARDS strategies.

Pleural Drainage Management

• Ensure adequate chest tube placement with appropriate suction to prevent tension pneumothorax 4, 2
• Minimize negative intrapleural pressure from excessive suction, as this increases the pressure gradient across the fistula and worsens air leak 2
• Balance suction levels to drain infected pleural fluid while limiting air leak—typically requires reducing suction to -10 to -20 cm H₂O rather than standard -20 cm H₂O 2

VV-ECMO for Refractory Cases

For patients with persistent large-volume air leaks preventing adequate ventilation or oxygenation, VV-ECMO allows ventilator settings even lower than ultra-protective levels and facilitates fistula healing:

• VV-ECMO permits near-apneic ventilation, eliminating the pressure gradient driving air through the fistula 1
• In a case series of four ARDS patients with BPF, all achieved fistula closure and survived to discharge when managed with VV-ECMO and minimal ventilatory support 1
• This approach should only be implemented at centers with ECMO expertise 5

Bronchoscopic Interventions

For persistent air leaks despite optimized ventilator management, endobronchial valve (EBV) placement offers definitive treatment:

• EBV placement provides immediate resolution of air leak and may facilitate liberation from mechanical ventilation 6
• In three mechanically ventilated ARDS patients with high-volume BPF, EBV placement led to immediate PAL resolution and successful extubation 6
• Alternative bronchoscopic options include sealing agents applied directly to the fistula site, particularly in poor surgical candidates 4

Lung Isolation Strategies

In refractory cases, consider independent lung ventilation (ILV) using a double-lumen endotracheal tube:

• ILV allows differential ventilation of each lung, minimizing pressures to the affected side while maintaining adequate ventilation of the unaffected lung 2
• This technique requires specialized expertise and careful monitoring 2

Modified ARDS Management Principles

While standard ARDS therapies must be modified, maintain these core principles where possible:

• Continue lung-protective ventilation principles (plateau pressure <30 cm H₂O when achievable) 3
• Avoid prone positioning in patients with large air leaks and chest tubes due to risk of tube dislodgement and impaired drainage 2
• Avoid neuromuscular blockade initially, as spontaneous breathing may reduce mean airway pressure and air leak 2
• Use conservative fluid management to minimize pulmonary edema, which is even more critical given impaired gas exchange 5
• Avoid prolonged lung recruitment maneuvers, which dramatically increase air leak 3

Monitoring Requirements

• Continuously assess air leak volume through chest tube drainage system 2
• Monitor for signs of tension pneumothorax, particularly when adjusting ventilator settings 4
• Serial chest imaging to assess fistula healing and pneumothorax resolution 2
• Arterial blood gases to guide permissive hypercapnia limits 1

Common Pitfalls

• Applying standard high-PEEP ARDS strategies worsens air leak and prevents fistula healing 2
• Excessive negative pleural suction increases the pressure gradient across the fistula 2
• Delaying consideration of ECMO in patients with refractory hypoxemia and large air leaks 1
• Attempting prone positioning with active large-volume air leaks risks catastrophic complications 2