Can intrapleural fibrinolytic therapy be used in a patient with a bronchopleural fistula?

Intrapleural Fibrinolytic Therapy with Bronchopleural Fistula

Intrapleural fibrinolytic therapy is contraindicated in patients with bronchopleural fistula and should be discontinued immediately if a fistula develops during treatment.

Evidence for Contraindication

The presence of bronchopleural fistula represents an absolute contraindication to intrapleural fibrinolytic therapy based on clinical experience:

• In a pediatric series of 72 patients receiving intrapleural fibrinolytics, treatment was discontinued in one patient specifically due to development of bronchopleural fistula during therapy 1
• The authors explicitly concluded that "in all patients with loculations except those with a bronchopleural fistula, intrapleural fibrinolytic treatment should be tried," directly excluding this population 1

Physiologic Rationale

The mechanism of fibrinolytic action creates specific risks in the presence of bronchopleural fistula:

• Fibrinolytics work by lysing fibrinous septations and clearing lymphatic pores, which dramatically increases pleural fluid drainage (73-93% increase in drainage rates) 2, 1
• This increased fluid mobilization can result in massive fluid shifts into the bronchial tree through the fistula, potentially causing drowning, aspiration pneumonia, or acute respiratory decompensation
• The standard protocol involves clamping the chest tube for 1-4 hours after instillation, which would allow fibrinolytic-laden fluid to track through the fistula into the airways 3, 1

Management Algorithm When Fistula is Present

If bronchopleural fistula is identified in a patient with loculated pleural effusion:

1. Do not initiate fibrinolytic therapy 1
2. If fibrinolytics are already running, discontinue immediately 1
3. Optimize chest tube drainage with attention to minimizing negative intrapleural pressure, as excessive suction increases airflow across the fistula 4
4. Consider contrast-enhanced CT to fully characterize the fistula and assess for undrained collections 5
5. Proceed directly to thoracic surgery consultation for definitive management, as medical drainage strategies are insufficient 5
6. Consider advanced bronchoscopic interventions (endobronchial valves, occlusion devices, or tissue adhesives like BioGlue) as temporizing measures or definitive treatment 4, 6

Critical Pitfall to Avoid

Do not attempt to "treat through" a bronchopleural fistula with fibrinolytics hoping the loculations will resolve first—this approach risks catastrophic airway flooding and respiratory failure. The single documented case of fibrinolytic discontinuation due to fistula development underscores this is a recognized complication requiring immediate cessation 1.