Bronchopleural fistula slide

1. Management of
Bronchopleural Fistula
氣管肋膜廔管
Dr Grace SM Lam
ICU Friday Lecture
16th January, 2009

2. Bronchopleural Fistula
 Communication between the bronchial tree &
pleural space
 Mortality varies between 18-67%
 Aetiology
 Postoperative 2/3
 Non-postoperative 1/3

3. Post-operative BPF
 Most commonly follows pneumonectomy (0-
9% v 0.5% in lobectomy)
 Predisposing factors:
 Rt pneumonectomy (shorter Rt main bronchus &
single Rt bronchial artery)
 Uncontrolled preoperative pleural /pulmonary
infection
 Preoperative irradiation
 Trauma
 Postoperative positive pressure ventilation
 Faulty closure of bronchial stump

4. Day 1
Day 2
Day 14
Day 30
Post-pneumonectomy CXRs
Radiographics 2006;26:1449-1468

5. Acute Post-pneumonectomy
BPF
Reappearance of air
OR a drop in air-
fluid level >1.5cm
Mediastinal
shift
Subcutaneous or
mediastinal
emphysema
Contralateral lung
consolidation
from
transbronchial
spill
Tension pneumothorax
& Pulmonary flooding
Day 22
Radiographics 2006;26:1449-1468

6. Non-postoperative BPF
 Causes:
 Necrotizing pneumonia, TB, lung abscess &
empyema
 ARDS
 Persistent spontaneous pneumothorax
 Thoracic trauma
 Iatrogenic (line placement, pleural biopsy, FOB)
 Irradiation & chemotherapy

7. Clinical Presentation
 Persistent air leak >24 hours after the
development of pneumothorax
 Exclude other causes of persistent air leak
 An external air leak
 Extra-thoracic location of side holes
 Disconnections

8. Clinical Presentation
 Acute
 Sudden SOB, hypotension, coughing up of fluid
& blood
 Subacute
 Insidious onset with fever, wasting, minimally
productive cough
 Chronic
 Fibrosis of pleural space prevents mediastinal
shift

9. Diagnosis
 Clinical
 Instillation of methylene blue through stump
followed by its detection in chest tube
 Inhalation of different concentrations of
oxygen and N2O followed by changes in gas
concentration in post-pneumonectomy space
 CT scan to delineate the aetiology
 Bronchoscopy is both diagnostic &
therapeutic

10. General Management
 Drainage of
pneumothorax &
infected pleural space
with appropriate size
chest tube(s)
 Pulmonary flooding:
Airway control &
position affected lung
down
 Treat underlying cause,
especially infection
 Maintain nutritional
status
Flow through a tube varies
exponentially with the radius of
the tube

11. Mechanical Ventilation
 BPF offers a pathway of least resistance
(or high compliance)
 Potential problems
 Significant loss of tidal volume (VT)
 ↓ CO2 excretion
 ↓Utilization of inspired O2
 Failure to maintain PEEP
 Air flow through fistula delays healing
 Inappropriate cycling of ventilator

12. Conventional Ventilation
 Goal is to maintain adequate ventilation
& oxygenation while↓fistula flow
 Minimize the pressure gradient between
airway & pleural space
 Minimize mean airway pressure
 Lowest effective tidal volume
 Shorten inspiratory time
 Least number of mechanical breaths
 Limit PEEP
 Discontinue /minimize suction on chest tubes

13. Chest 1986; 90: 321-323
Persistent Bronchopleural Air Leak During
Mechanical Ventilation. A Review of 39 Cases.
 A retrospective review
 Jan 1977 – Dec 1980
 County hospital and regional trauma & burn
center in Seattle
 Consecutive patients who received mechanical
ventilation & developed persistent air leak >24hrs
 Patients after cardiac surgery or pulmonary
resection were excluded

14. Chest 1986; 90: 321-323
Received MV
1700
Persistent Air Leak
39 (2%)
Trauma
27
Chest
22
Non-chest
5
Non-traumatic Surgical Illness
4
Abdominal
2
Burn
2
Medical Illness
8
Pneumonia 4
TB 1
Pancreatitis 1
Near-drowning 1
Sepsis 1

15. Chest 1986; 90: 321-323
 Overall mortality 67%
 Increased mortality in:
 Late air leak (94% v 45%; P=0.002)
 Diagnoses other than chest trauma (P<0.005)
 Maximum air leak >500ml/breath (100% v
57%; P<0.05)
 Pleural space infection (87% v 54%; P<0.05)

16. Chest 1986; 90: 321-323
 Mode of MV
 Assist-control ventilation 33
 Intermittent mandatory ventilation 6
 Only 2 patients had persistent acidemia
PH<7.30 despite adjustment of ventilatory
settings
BPF can usually be managed by conventional
ventilation.
The need for special ventilation techniques is
uncommon.

17. Failure of Conventional
Ventilation…
 Options:
 Chest tube manipulation
 Intermittent inspiratory chest tube occlusion
 Application of intrapleural pressure at expiration
 Independent lung ventilation
 High frequency ventilation
 Extracorporeal oxygenation

18. Intermittent Inspiratory Chest Tube
Occlusion
 Synchronizing chest
tube occlusion at
inspiration
 Limit loss of tidal
volume on inspiration
 Restores pulmonary
gas exchange &
promotes healing of
BPF
During Inhalation During Exhalation
Chest 1990; 97: 1426-1430

19. Independent Lung Ventilation
Independent lung ventilation Indication
Anatomical lung separation Massive hemoptysis
Whole lung lavage for pulmonary
alveolar proteinosis
Copious secretions (e.g. bronchiectasis,
lung abscess)
Physiological lung separation Unilateral parenchymal injury
Aspiration
Pulmonary contusion
Pneumonia
Unilateral pulmonary edema
Single lung transplant (post operative
complications)
Bronchopleural fistula
Unilateral bronchospasm
Severe bilateral lung disease failing
conventional ventilationa
Crit Care. 2005; 9(6): 594–600

20. Methods of Lung Separation
Endobronchial Blockers Double Lumen ETT

21. Methods of Lung Separation
Endobronchial Blockers
 Can be passed
 Along the side, or
 Into the lumen
Of the single lumen ETT
 Final placement requires
bronchoscopic guidance
 Does not allow ventilation of
the obstructed lung (for
anatomical lung separation)

22. Methods of Lung Separation
Double Lumen ETT
 For independent lung ventilation

23. Size of double lumen ETT
 Appropriately sized to allow:
 Adequate functional separation of the lungs
 Access for suctioning and bronchoscopy
 Prevent migration of the tube
Tube size (F)
Circumference
(mm)
Lumen diameter
(mm)
Indication
35 38.0 5.0 Pediatrics
37 40.0 5.5 Small adults
39 44.0 6.0
Medium adults,
usual female size
41 45.0 6.5
Large adults, usual
male size

24. Double Lumen ETT Placement
 Confirming position by ascultation following
sequential clamping is inaccurate in 38%
 Bronchoscopic confirmation is
recommended
 For a left-sided double lumen ETT,
bronchoscopy via:
 Tracheal port ~ Carina visualized, without
herniation of bronchial cuff
 Bronchial port ~ LUL orifice visualized

25. Independent Lung Ventilation
 For unilateral BPF
 Unaffected lung:
 Conventional ventilation
 Affected lung:
 Conventional ventilation with lower mean
airway pressure
 CPAP at pressure just below the critical opening
pressure of BPF
 High frequency ventilation

26. High Frequency Ventilation

27. High Frequency Ventilation
Conventional Ventilation
 Gas transport occurs by
bulk flow /convection &
molecular diffusion
 VA = f (VT – VDS)
High Frequency Ventilation
 Delivery of small tidal
volumes (VT≦VDS) at
supra-physiologic
frequencies
Governs lung
volume &
oxygenation
Frequency
Tidal volume & CO2
elimination

28. Gas Transport in HFV
 Longitudinal gas
transport :
 Coaxial flow
 Molecular diffusion
 Mixing of fresh &
exhaled gas :
 Lateral diffusion
 Turbulent flow at airway
bends & bifurcations
 Intra-alveolar pendelluft
 Most proximal alveoli by
bulk flow

29. HFV in BPF
 Flow through an air leak is proportional to:
 Cross-sectional area of the leak
 Time held at high airway pressure
∴High frequency ventilation may reduce fistula
leak

30. HFV in BPF
 Superior to conventional ventilation in
controlling PCO2 & PO2 in proximal BPF &
normal lung parenchyma
 Controversial in peripheral BPF with
parenchymal disease (e.g. ARDS)
 Initial settings:
 Begin with MAP similar to or slightly lower than
that of conventional ventilation
 Use higher frequency (13-15Hz)
 Amplitude to achieve minimal chest movement

31. Potential Complications of HFV
 Suboptimal humidification
 Inspissation of airway secretions
 Necrotizing tracheobronchitis
 Gas trapping

32. Treatment of BPF
Operative
 Drainage of infected
pleural space, closure of
BPF, and obliteration of
dead space:
 Omental flap
 Transsternal
transpericardial bronchial
closure
 Eloesser muscle flap
 Thoracoplasty
Non-operative
 Conservative
 Chemical pleurodesis via
chest drain
 Bronchoscopic methods
Underwater seal
Patient
60cm
ANZ J Surg. 2006 Aug;76(8):754-6

33. Bronchoscopy in BPF
 Diagnostic:
 Direct visualization of proximal fistula
 Distal fistula localized by systematically
occluding bronchial segments by balloons
 Therapeutic:
 Distal small fistulas (~1mm) can be sealed by
various agents:
Glue, blood patch, coils, gel foams, lead shots
 No evidence to support the use of one over
another

34. Bronchoscopy in BPF
Amplatzer device
Commonly used for closure
of atrial septal defects.
For closure of larger BPF.
Large range of device sizes &
can be matched to size of
fistula.
Chest 2008; 133(6): 1481-4
Endobronchial valve
(Emphasys)
Designed primarily for
endoscopic lung volume
reduction in emphysema.
One-way valve that prevents
entry of air but allows
drainage of secretions.
Thorax 2007; 62: 830-3

35. Bronchoscopy in BPF
 Endobronchial
Watanabe Spigot
(EWS) (Novatech,
Grasse, France)
 A silicone-made
bronchial filler for
bronchial occlusion
 Flexible bronchoscope
under LA
J Bronchol 2003; 10: 264-7

36. Bronchial Occlusion With
Endobronchial Watanabe Spigot
J Bronchol 2003; 10: 264-7
 63 cases in Japan between April 2000 and
March 2002
 40 intractable pneumothorax
 12 pyothorax with bronchial fistula
 7 pulmonary fistula, 1 bronchial fistula
 1 bronchobiliary, 1 bronchoesophageal fistula,
and 1 bronchogastric fistula

37. Bronchial Occlusion With
Endobronchial Watanabe Spigot
 Technically
successful bronchial
occlusion
 In 58/60 (96.7%)
 Average 4 EWS/case
used
J Bronchol 2003; 10: 264-7

38. Take Home Messages
 BPF is an abnormal communication between
bronchial tree & pleural space associated with
significant mortality
 No established guidelines in the management
of BPF
 Early recognition, drainage, & management of
infection are critical
 Recognizes the potential problems with
positive pressure ventilation, although
conventional ventilation usually suffices
 List of available options represent personal
experience not subjected to vigorous testing

39. References
 Radiographics 2006;26:1449-1468
 Crit Care 2005; 9(6): 594–600
 Chest 1986; 90: 321-323
 Chest 1990; 97: 1426-1430
 Crit Care 2005; 9(6): 594–600
 Chest 2005; 128(6): 3955-65
 Chest 2008; 133(6): 1481-4
 Thorax 2007; 62: 830-3
 J Bronchol 2003; 10: 264-7

40. THANK YOU