What is the management of a broncho pleural (bronchopleural) fistula?

Management of Bronchopleural Fistula

Insert a large-bore chest tube (24F-28F) immediately, connect it to water seal with controlled suction, and consult thoracic surgery early if the air leak persists beyond 4 days. 1, 2

Initial Diagnostic Approach

Confirm the diagnosis with CT chest with IV contrast, which serves as the gold standard for detecting bronchopleural fistulae and identifying underlying causes such as necrotizing pneumonia, pulmonary abscess, or empyema. 3 Direct CT signs include visualization of a fistulous tract between the bronchus and pleural space, while indirect signs include air bubbles beneath the bronchial stump. 3

• Use ultrasound guidance to determine optimal chest tube placement site for any associated fluid collections. 1
• Perform bronchoscopy only when there is high suspicion of bronchial obstruction or to localize the fistula for potential endoscopic intervention. 3, 4

Immediate Management: Chest Tube Drainage

Place a 24F to 28F chest tube at the optimal site guided by ultrasound imaging to ensure proper drainage of both air and fluid. 1 This larger bore is essential for managing the potentially large air leaks associated with BPF. 2

• Connect the chest tube to a water seal device with controlled suction to evacuate fluid and air. 1
• Apply graded and progressive suction until fluid output decreases to less than 100 mL/day. 1
• Never clamp a bubbling chest drain as this may precipitate tension pneumothorax, particularly in ventilated patients. 1, 2
• Monitor drainage volume and character continuously. 1

Critical Safety Point for Ventilated Patients

In mechanically ventilated patients, clamp the ventilator circuit before assessing the pleural cavity during chest tube placement to prevent positive pressure spreading of pleural air or fluid. 3 This minimizes aerosol generation and prevents tension pneumothorax. 3

Management of Associated Empyema

When BPF occurs with empyema, ensure adequate drainage of infected fluid as the first priority before attempting definitive fistula closure. 1, 4 The empyema cavity must be controlled for successful fistula management. 4, 5

• Sample pleural fluid within 24 hours for diagnostic purposes in all suspected pleural infections. 3
• Measure pleural fluid pH with a blood gas analyzer (using heparinized samples) unless the fluid is visibly purulent. 3
• Consider intrapleural fibrinolytics in complicated cases with loculated collections. 1

Timing of Surgical Consultation

Obtain thoracic surgery consultation if the air leak persists beyond 4 days of appropriate chest tube drainage. 1, 2 This 4-day threshold represents the critical decision point between conservative and surgical management. 1

• Thoracoscopy (VATS) is the preferred surgical approach for persistent BPF. 1
• Surgical options include thoracoscopy, limited thoracotomy with fistula repair, bullectomy if indicated, and pleurodesis. 2
• Early surgical intervention improves outcomes, as protracted treatment increases secondary complications and adversely affects survival. 4

Non-Surgical Options for High-Risk Patients

For patients who are poor surgical candidates, consider chemical pleurodesis with talc slurry (4-5g in 50mL normal saline) or doxycycline as the preferred sclerosing agents. 1, 2

• Avoid corticosteroids during pleurodesis as they reduce effectiveness. 1
• Never perform bilateral simultaneous pleurodesis due to risk of respiratory failure. 1
• Chemical pleurodesis should be considered after 4 days of persistent air leak in non-surgical candidates. 2

Bronchoscopic Interventions

For small fistulae or high-risk surgical patients, bronchoscopic closure techniques may serve as a bridge to definitive therapy or as the only option. 4, 6

• Endobronchial valves designed for emphysema treatment can successfully close distal bronchopleural fistulae. 7
• Methacrylate adhesive can be delivered through a catheter placed through the bronchoscope working channel (avoiding direct contact with the instrument). 3
• Bronchoscopic methods include various glues, coils, and sealants, though therapeutic success is variable. 6
• Percutaneous synthetic hydrogel surgical sealant shows promise with 80% complete resolution in post-ablation BPF. 8

Monitoring and Criteria for Chest Tube Removal

Perform serial chest radiographs to confirm proper chest tube placement, resolution of pneumothorax, and lung re-expansion. 1, 2

• Discontinue suction once the air leak resolves. 1
• Remove the chest tube only when drainage is less than 100-150 mL/24 hours AND the air leak has completely resolved. 1, 2
• Premature chest tube removal risks recurrent pneumothorax and treatment failure. 2

Special Infection Control Considerations

For patients with COVID-19 or suspected infection, use full personal protective equipment (Level 2 PPE) as pleural procedures should be considered aerosol-generating. 3, 1

• Perform procedures in negative pressure rooms when possible. 3
• Ensure procedures are performed by trained staff to minimize duration and complications. 1
• Take extra care to avoid open communication with the pleural space during tube placement to prevent droplet and aerosol emission. 3

Assessment Timeline

Assess effectiveness of drainage and resolution of fever/sepsis 5-8 days after starting chest tube drainage and antibiotics, documenting results in clinical notes. 3 Patients without effective pleural drainage at this assessment should be discussed with thoracic surgery. 3