Bronchopleural fistula


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Bronchopleural fistula

  1. 1. Dr Chiranjib Bhattacharyya Associate Professor Dept. Of Anaesthesiology IPGMER KOLKATA
  2. 2.  Communication between bronchial tree and pleural space  High morbidity and mortality  Prolonged hospital stay  No standard treatment guidelines or consensus  Aetiology : 1.postoperative – 2/3 2.non-operative – 1/3
  3. 3. CLASSIFICATION OF AIR LEAKS  Alveolopleural fistula(APF):pulmonary-pleural communication distal to segmental bronchus, common after lung resection except pneumonectomy, heal conservatively.  BPF: communication between a mainstem, lobar or segmental bronchus and the pleura lined cavity, usually require surgical intervention
  4. 4.  4.5%-20% after pneumonectomy and 0.5% after lobectomy  Predisposing factors: 1.h `Rt.pneumonectomy 2. Uncontrolled pleural/pulmonary infection 3. Preop. radiation,steroid,cirrhosis,diabetes 4. Uncorrected low serum albumin, anaemia 5. Malignancy 6. Contd.mechanical ventilation for more than 24h 7. H influenzae in sputum 8. Fever, high ESR
  5. 5.  Main bronchus,intermdt bronchus has higher risk compared to lobar bronchus  Long bronchial stump, residual tumour, excessive peribronchial and paratracheal dissection-harmful  Routine coverage of stump with omentum, intercostal muscle flap, pleural flap, pericardial fat esp after right pneumonectomy suggested
  6. 6. NONPOSTOPERATIVE BPF         Infection- pneumonia, lung abscess,TB,empyema ARDS Persistent spontaneous pneumothorax Thoracic trauma Iatrogenic eg line placement,lung biopsy,pleural biopsy bronchoscopy Necrotising lung disease associated with radiation,chemotherapy Spontantaneous rupture of bulla,cyst Erosion of bronchial wall: malignancy,FB,chr.inflammation
  7. 7. CLINICAL PRESENTATION o o o o o Usually 7-15 days following a lung resection Early (1-7days ), intermediate ( 8-30 days ) and late ( more than 30 days ) As complication of pleuropulmonary infection-any time during the course of the illness Early indicators: reappearance of fever,increased cough with purulent/serosanguinous sputum Persistent bubbling from the chest drain
  8. 8. CLINICAL PRESENTATION (CONTD)     ACUTE: sudden onset of dyspnoea,cough,expectoration of purulent material,hypotension,subcutn.emphysema,shifting of trachea and mediastinum. SUBACUTE: insidious onset of fever,malaise,wasting,minimally productive cough CHRONIC: associated with infectious disease,minimal mediastinal shift due to pleural and mediastinal fibrosis,not life threatening,adequate gas exchange in healthy lung Systemic features of sepsis
  9. 9. POST-PNEUMONECTOMY CXRS Day 2 Day 1 Day 14 Day 30 Radiographics 2006;26:1449-1468
  10. 10. ACUTE POST-PNEUMONECTOMY BPF Day 22 Reappearance of air OR a drop in airfluid level >1.5cm Subcutaneous or mediastinal emphysema Tension pneumothorax & Pulmonary flooding Mediastinal shift Contralateral lung consolidation from transbronchial spill Radiographics 2006;26:1449-1468
  11. 11. DIAGNOSIS  CLINICAL  Persistent air leak: >24h after development of pneumothorax  Exclude other causes of persistent air leak: external air leak 2.extrathoracic location of side holes 3.disconnections
  12. 12. DIAGNOSIS (CONTD.)  Plain x-rays may reveal following features of BPF : 1.steady increase in intrapleural airspace 2.appearance of a new air fluid level (indicates level of the BPF) 4.development of tension pneumothorax 5.drop in air fluid level exceeding 2cm (in absence of chest tube )
  13. 13. DIAGNOSIS CONTD.  Role of CT Scan: demonstrates      pneumothorax,pneumomediastinum,underlyin g lung pathology Demarcation of actual fistulous communication Role of FOB: can confirm and localise the BPF FOB and selective bronchography Visualisation of continuous return of air bubbles on bronchial wash Selective instillation of methylene blue into segmental bronchi: appears in chest drain,sputum
  14. 14.  FOB aided placement of balloon-tipped catheter in selective airway: inflation of balloon eliminates leak  Combined FOB and Capnography : polyurethane catheter passed through br.scopic channel and introduced into different bronchi  BPF suggested by loss of capnographic tracing: affected bronchus communicates to atmosphere through chest tube
  16. 16. Post pneumonectomy bronchopleural fistula, (A) right hydropneumothorax, (B) FOB showed a possible fistulous opening at the right bronchial stump, (C) methylene Blue injected at the suspected site, (D) appearance of dye in the pleural drainage system confirmed the diagnosis.
  17. 17. DIAGNOSIS (CONTD.)  Changes in gas concentration in pneumonectomy     cavity after inhalation of different conc. of O2,N2O Ventilation scintigraphy using radioactive gases, eg. 133Xe that accumulate in pleural space within and remain trapped in the pleural space in washout study High incidence of false negative results Inhalation of radio-labelled aerosols with planar and SPECT imaging: requires patient cooperation, false positives occur, direct estimation of size of BPF not possible
  18. 18.  1.The largest(C): continued bubbling through chest tube,least common,pts on mech.ventilation  2.The 2nd largest(I): air leak only during inspiration,pts on mech. ventilation with large APF or small BPF  3.The 3rd largest(E): air leak only during expiration,after lung surgery due to APF  4.The smallest(FE): air leak only during forced expiration eg. coughing,common after lung resection  Small leaks heal with underwater drains but larger leaks may require suction
  19. 19. CONSEQUENCES OF BPF   Persistent pneumothorax: air escaping through the BPF delays healing of the tract  Inadequate ventilation: significant loss of TV  Pendelluft: seen in early BPF when mediastinum is mobile  V/Q mismatch  Infection of pleural space  Most common cause of death in BPF: aspiration pneumonia and ARDS,tension pneumothorax
  20. 20. PROBLEMS WITH LARGE BPF IN ICU Difficult to wean from ventilator Inability to apply PEEP Failure to expand the remaining lung Hypoxia, hypercarbia May need dual ventilation May need HFV High mortality: occurrence of BPF during mechanical ventilation identifies pts. with high mortality
  21. 21. TREATMENT OF BPF  Treatment options include: surgical procedures,medical therapy,bronchoscopic- guided placement of glue,coils,sealants etc  Initial treatment: control of life-threatening conditions  Tension pneumothorax: urgent insertion of chestdrain  Pulmonary flooding: immediate airway control,postural drain with affected side down  Major bronchial stump dehiscence: immediate resuture with reinforcement
  22. 22. TREATMENT (CONTD)  Aggressive management of underlying       comorbidities Haemodynamically unstable pt. with varying degrees of resp. failure Superadded sepsis Poor nutrition, hypoalbunaemia, anaemia Unresolved empyema, underlying tubercular/fungal infection Poor candidates for a second surgical procedure Need care in ICU setup
  23. 23. TREATMENT ( CONTD.) o Drainage of pleural space with proper antimicrobial coverage o Enteral or parenteral nutrition o Correction low albumin and haematocrit o Mechanical ventilatory support if required
  24. 24. ROLE OF CHEST TUBE IN BPF       Indicated in all pts. with high flow BPF and drainage of empyema Add positive intrapleural pressure during expiration to reduce air leak and maintain PEEP Intermittent occlusion during inspiratory phase to decrease BPF flow Useful in patients with ARDS Can function as foreign body and delay healing Predispose to infection at insertion site and pleural space
  25. 25. CHEST TUBE (CONTD.)  Loss of tidal volume  Abnormal gas exchange  Inappropiate ventilator cycling  Tube should of sufficient diameter to allow free drainage of air leak  Flow varies with 5th power of tube radius in clinical situations due to turbulent flow of moist air( Fanning equation )  Pleurodesis: sclerosing agent eg bleomycin can be passed through tube
  26. 26.  Air leaks may range from 1-16L/min  Loss of effective TV and PEEP, incomplete lung expansion,CO2 retention, auto-triggering of ventilator, severe hyperventilation  Excess use of sedatives, muscle relaxants  Goal: 1. keep airway pressure at or below critical opening pressure of fistula 2.adequate pleural space decompression to allow lung re-expansion
  27. 27. Increased chest tube suction increases flow through BPF, so use least possible pressure or none at all  Limiting the amount of PEEP during ventilation  Limiting effective tidal volume  Shortening the inspiratory time  Reducing the respiratory rate  Reducing the proportion of minute volume supplied by ventilator  Differential lung ventilation using a DLT  Independent lung ventilation using 2 ventilators 
  28. 28. HIGH FREQUENCY VENTILATION IN BPF       Results are conflicting More useful in pts. with normal lung parenchyma and proximal BPF Can be useful in pts. with massive air leak Have been successfully used in pts. with bilateral BPF Less effective in pts. with bilaterally diseased noncompliant lungs Major handicap: doesn’t allow isolation of lungs
  29. 29. THERAPEUTIC BRONCHOSCOPY IN BPF o Allows inspection of the stump o Confirms location and size of the BPF o Bronchoscopy aided application of sealant substance can be tried o Intrabronchial stents, valves,embolisation coils etc have been used o Suitable for small fistulas ( <5mm diam ) o Proximally located fistula-mainstem, lobar or segmental bronchi are more suitable o Useful alternative in patients not proper candidates for surgery
  30. 30. SURGICAL PROCEDURES IN BPF • Decortication of lung • Revision of bronchial stump • Closure of fistula with muscle flap from intercostal space • Thoracoplasty combined with pedicle muscle flap to cover bronchial stump • Resection of diseased chronically infected lung segments
  31. 31.  Experienced thoracic anaesthesiologist  Problems in anaesthesia for BPF pts.:  1.Isolation of the healthy lung reqd.  2.Prevention of tension pneumothorax during PPV  3.Inadequate ventilation due to loss of gas through fistula  4.Significant intraoperative blood loss  5.Patient preparation may be suboptimal  6.Early extubation and avoidance of postoperative PPV desirable
  32. 32. Assessment of possible loss of TV through the fistula:  bubble flow through chest drain continous or intermittent  Quantification of size of BPF: inhaled TV– exhaled TV  Nonintubated pt.: tight fitting mask and fast responding spirometer  Intubated pt.: direct attachment of spirometer to ETT  Larger the leak,greater need to isolate BPF by lung isolation  Devices: DLT,SLT,independent bronchial blocker 
  33. 33. ANAESTHESIA FOR BPF (CONTD.)  DLT advantages:  1.most secure method of isolation  2.allows easy bilateral suction and ventilation  3.differential lung ventilation possible  DLT disadvantage: most difficult to place in awake patients under topical anaesthesia of airway  SLT disadvantage:  1.doesnt allow easy suction or ventilation of affected lung  2. not designed for endobronchial use  3.if placed in R mainstem bronchus will obstruct orifice of RUL
  34. 34. ANAESTHESIA FOR BPF (CONTD.)          Bronchial blocker advantages: 1.can be deflated to suction or ventilate BPF lung 2.allows lobar isolation Disadvantage: least secure method of lung isolation Ability to deliver PPV must be assessed Working chest drain prior to induction SLT safe to use: if fistula small, chronic,uninfected DLT best choice for PPV: if significant airleak present Usual MV can be delivered to healthy lung,no loss through fistula and no risk of contamination on turning the pt.
  35. 35. ANAESTHESIA FOR BPF (CONTD.)  o Emergency situation: SLT can be used,provides protection and ventilation to healthy lung o Non pneumonectomy pt.: BB can be placed through ETT into mainstem bronchus of affected side,less stable,less protection to the healthy lung o Post pneumonectomy pt.: BB is not an option due to short length of bronchial stump available o Anaesthetic management options include: o 1.awake fibreoptic intubation with SLT,DLT or BB. o Induction of GA after lung isolation is achieved
  36. 36. ANAESTHESIA FOR BPF (CONTD.)   Safest method but technically most difficult  Requires excellent pt. cooperation and thorough airway topical anaesthesia  2.Induction of GA maintaining spont.ventilation using deep inhalational anaesthesia  PPV avoided lungs are isolated  Breath holding and laryngospasm may nessecitate unplanned use of PPV  Vigorous coughing in either technique may provoke spillover into healthy lungs and reopen a fistula  Significant hypotension can occur in elderly,debilitated pts.
  37. 37. 3.If airway is thought to be easy, rapid sequence induction can be done avoiding PPV until lung isolation.  Position for induction: head up position maintained as long as possible with 30deg lateral tilt keeping diseased lung down  Post pneumonectomy pts.; DLT or SLT placed under direct vision with help of FOB for accurate placement and avoiding injury to bronchial stump  Suction of chest tube to be avoided during induction: to reduce loss of TV with PPV 
  38. 38. Chest open, SLT used, excessive air leak: lungs packed off and manual compression of fistula by surgeon  Rigid bronchoscope can be introduced under topical anaesthesia of airways or inhalation anaesthesia: observation of fistula, suction,positioning of endobronchial tube or BB, jet ventilate the healthy lung  Extubation: as soon as feasible as neg. pr. ventilation is best  Bronchial tree examined with FOB before extubation 
  39. 39. ANAESTHESIA FOR BPF (CONTD.) If postop ventilation is necessary DLT is not changed Thoracic epidural analgesia for post operative analgesia TEA has been used as sole anaesthetic technique in BPF closure in elderly debilitated pts.
  40. 40. REFERENCES     Sarkar P et al Diagnosis and Management Bronchopleural Fistula Indian J Chest Allied Sci 2010;52:97-104 Manuel L et al Bronchopleural Fistulas An Overview of the Problem With Special Focus on Endoscopic Mnagement CHEST 2005;128:39553965 Sanjay O P et al Management of Bronchopleural Fistula. Core Topics in Thoracic Anaesthesia Chapter 27,OUP 2009 Principles and Practice of Anaesthesia for Thoracic Surgery.ed P Slinger 2011 Pg 467-71