From the Guidelines
Bronchopleural fistula (BPF) closure in tubercular empyema typically requires a multifaceted approach combining medical and surgical interventions, with the primary recommendation being to start with anti-tubercular therapy (ATT) and adequate drainage of the empyema cavity. The management of BPF in tubercular empyema involves:
- Starting with anti-tubercular therapy (ATT) consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid and rifampicin for at least 4 additional months 1.
- Adequate drainage of the empyema cavity, usually via tube thoracostomy or image-guided drainage.
- Considering surgical intervention for persistent BPF, with options including direct suturing of the fistula, muscle flap transposition, or thoracoplasty for larger defects.
- Using bronchoscopic approaches for smaller fistulas, such as fibrin glue, endobronchial valves, or autologous blood patch.
- Providing nutritional support, with albumin levels maintained above 3g/dL and adequate caloric intake ensured. The closure of BPF in tubercular empyema is challenging due to the chronic inflammation and fibrosis from tuberculosis, which compromise tissue healing, while the persistent air leak through the fistula prevents lung expansion and prolongs the empyema 1. It is essential to address both the infection and the anatomical defect simultaneously to break the difficult cycle of BPF in tubercular empyema. In cases where surgery is necessary, it should be performed by experienced thoracic surgeons, and the decision to involve a surgeon should be made early in the treatment process 1. The treatment of BPF in tubercular empyema requires a comprehensive approach, taking into account the patient's overall health, the severity of the disease, and the potential risks and benefits of different treatment options 1.
From the Research
BPF Closure in Tubercular Empyema
- The closure of a bronchopleural fistula (BPF) in tubercular empyema can be achieved through a combination of tube thoracostomy or catheter drainage and high-end dosing of anti-TB drugs, as reported in a case study 2.
- Therapeutic drug monitoring (TDM) can be used to guide high-end drug dosing and improve the chances of a favorable outcome 2.
- The management of tuberculous BPF requires an individualized approach based on the patient's condition and response to treatment, and may involve anti-tuberculosis therapy, intercostal drainage and suction, and in some cases, more invasive surgeries such as decortication, thoracoplasty or pleuropneumonectomy 3.
- The effective management of BPF in tuberculosis demands a multidisciplinary approach, especially when compounded by concurrent infections and severe malnutrition 4.
- Surgical intervention, such as pedicled latissimus dorsi muscle flap transfer, may be required in refractory cases of BPF with empyema, and can be an effective treatment option 5.
- Intensified chemotherapy and surgical intervention should be considered in cases of chronic tuberculous empyema with BPF, as thick, calcified pleural walls can limit penetration of drugs into the infected empyema space, resulting in suboptimal drug concentrations and drug resistance 6.