ANESTHESIA CONSIDERATIONS

1. Presenter : DR. M.MADHU CHAITANYA
Moderator : DR. PRADEEP KUMAR DAS (assistant professor)
Great eastern medical school and hospital
ANESTHESIA CONSIDERATIONS
IN BRONCHO-PLEURAL FISTULA

2. Case report
•A 15-year-old male, weighing 49 kg was brought to emergency department ,9 days after
an injury to the right side of his chest by the steering wheel of a tractor.
•Patient had complaints of pain over the right side of chest and breathlessness soon after
the injury.
• He had no upper airway obstruction and there was no other associated injury.
• He was initially treated at a peripheral hospital, where intercostal drainage (ICD) was
placed.
•He was then referred to a centre of specialized facilities, where on fiberoptic
bronchoscopy near complete transaction of right main bronchus with bronchopleural fistula
was diagnosed.
• The right lung was collapsed.
•After further investigation and treatment, he was referred to tertiary centre for further
management.

3. •The patient was conscious and co-operative with stable heart rate and blood pressure
(Pulse rate = 92 beats/min, BP = 120/76 mmHg).
• Respiratory rate was 19 breaths per minute and peripheral
oxygen saturation was 92–97% on room air.
• On auscultation, air entry was absent on the right side of the chest.
• There was collection of 250 ml of straw colored fluid in the right ICD.
• Chest compression test was negative.
• There were no other associated injuries.
• ABG values on room air were within normal limits (pH = 7.46, PCO2 = 37, PO2 = 70
, HCO3- = 26.8, BE = 2.5).
•Chest radiograph and CT Scan showed right sided pneumothorax with collapsed lung,
absent broncho-pulmonary markings with ICD in situ

4. CX Ray showing right side pneumothorax with collapse of right lung.
Broncho-pulmonary marking are present only in the left lung field (white arrow)
not seen on the right side. Grey arrow shows the ICD in situ on the right side.

5. PLAN OF MANAGEMENT
Patient was planned for elective Thoracotomy under General anesthesia with
epidural anesthesia because of massive air leak through bronchopleural fistula.

6. PROCEDURE
 In the operating room, routine monitors were attached and an epidural catheter was
placed at T10-T11 level in the sitting position.
 Epidural infusion of Bupivacaine 0.25 % was started.
 Anesthesia induction with Fentanyl , Propofol and Rocuronium was done.
 Trachea was intubated using 32 Fr left-sided DLT.
The position of the tube was confirmed by fiberoptic bronchoscopy.
 Anesthesia was maintained with isoflurane in a mixture of Oxygen and Air
(1:2), fentanyl and vecuronium.
 Patient was positioned in left lateral position and ICD was removed.
Thoracotomy was done using a J-shaped incision in the 5th intercostals space.

7.  Intraoperative, decision for pneumonectomy was taken as there was severe
contusion and collapse of right lung and the margin of the transected right main
bronchus was sloughed and un repairable.
 Pulmonary vein and artery were clamped and tied separately and right bronchus was
cut and sutured.
 The absence of leak at suture site was confirmed by applying
positive pressure ventilation up to 40 cm H2O.
 A new ICD was placed in the 6th intercostal space and wound closed in layers.
 Intraoperative course was uneventful.
 At the end of surgery, patient was shifted to intensive care unit (ICU).

8. POSTOPERATIVE PERIOD
• Elective ventilation with DLT in situ was planned in the Postoperative Period
•In the ICU, patient received sedation and analgesia with midazolam and fentanyl along
with epidural analgesia .
• Patient was mechanically ventilated using pressure controlled mode (PCV) with following
ventilatory settings:
1. Peak inspiratory pressure of 20 cm H2O,
2. Respiratory rate 20 breaths/min,
3. I:E ratio 1:2
4. positive end expiratory pressure (PEEP) of 3 cm H2O.

9. Four hours later in the ICU, the stump leaked due to malposition of the
DLT, leading to difficulty in ventilation.
The tube was repositioned with fiberoptic bronchoscope in ICU and the
patient re-operated to repair the site of leak.
 Right thorax was opened through the same incision and major air leak
was detected from right main bronchus, which was then secured.
 After the surgery, patient was again shifted to ICU with DLT in situ and
this time patient was kept paralyzed with vecuronium infusion at 3 mg/h
for next 48 h.

10. The displaced left DLT into the stump of the right main bronchus (black arrow)
causing injury to the suture line. Right side of the thorax having ICD in situ
(white arrow).

11.  After two days, DLT was changed with 6 mm portex endo-tracheal tube using
fiberoptic bronchoscope with due care not to injure the stump.
The patient was electively ventilated for the next one day.
 On the third postoperative day, patient was weaned off the ventilator and
later tracheally extubated.
Further course in the hospital was uneventful and patient was discharged
home on 14th day

12. Definition
A bronchopleural fistula is a connection from the bronchial tree to the pleural space.
Miller cites three ways this can occur:
1. Rupture of a bronchus, bulla, cyst, or abscess
2. Erosion due to carcinoma or inflammatory disease
3. Stump dehiscence status post pneumonectomy
Incidence:
 2-11% after pulmonary resection
 Mortality of 5-70%

13. Etiology
I. Most commonly occurs due to giving away of bronchial suture after
pneumonectomy
II. Erosion of bronchus by carcinoma or chronic inflammation
III. Spontaneous drainage of lug abscess/ empyema cavity into bronchial
tree
IV. Traumatic rupture of bronchus/bulla/cyst{ by barotrauma/PEEP}
V. Penetrating chest wound

14. CLINICAL PRESENTATION
Usually 7-15 days following a lung resection
 Early (1-7days ),
 Intermediate ( 8-30 days ) and
 Late ( more than 30 days ) As complication of pleuro-pulmonary 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.

15. CLINICAL PRESENTATION
1. ACUTE: Sudden onset of dyspnea, cough, expectoration of purulent material,
hypotension, subcutn.emphysema,shifting of trachea and mediastinum.
2. SUBACUTE: Insidious onset of fever, malaise, wasting,minimally productive cough
3. 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.

16. Anesthesia Considerations
Inability to effectively ventilate these patients may be encountered due to
large air leak
Also positive pressure ventilation might increase air leak across BPF
causing tension pneumothorax and delayed healing of fistula.
Reduced alveolar ventilation on the other hand causes CO2 retention and
increased acidosis.
Reducing risk of contaminating healthy lung is important if empyema is
present
.

17. GOALS
Need for resuscitation & stabilization prior to OR:
– Fluids, vasopressors, antibiotics, chest tube placement
– If no chest tube in place prior to OR, thoracic surgeon must be
immediately available to place a chest tube
Intra operative goals:
– Lung protective ventilation
– Restrictive fluid strategy
– Maintenance of normothermia & normal metabolics
Optimization to facilitate postoperative extubation:
– Resuscitation
– Bronchial suctioning
– Bronchodilators
– Extubation to BiPAP

18. PRE-OPERATIVE ASSESSMENT
An assessment of the patient’s cardio-respiratory function.
Preoperative optimization - the presence of active infection / wheeze
should be identified and treated if possible.

19. Preoperative preparation and Premedication
1. Drainage of empyema
Empyema if present, should be drained before any surgery is done, to close the
BPF
This is done to avoid risk of tension pneumothorax during PPV
Drainage is done with person sitting up and leaning towards affected side
A drain to underwater seal system is left In the pleural cavity before anesthesia
Chest x ray should be take to determine efficacy of procedure

20. Estimation of size of BPF
Important as it determines the amount of air leak from the tidal volume administered
Two methods
1. Amount of ICD drain:
- After pneumonectomy if continuous drainage occurs , it implies that BPF is large
- If drainage is intermittent, it implies small size of BPF
2. Loss of tidal volume:
• Estimate loss of tidal volume between inspired and expired tidal volume
• Smaller difference between inspired and expired tidal volume implies smaller sized BPF
 This is done by connecting spirometer to
A tightly fitting face mask in non intubated patients
To ETT In intubated patiets

21. Investigations
1. CBP, bleeding time, clotting time, Creatinine, Urea, LFT, ECG
2. Neutrophilia, Raised total counts
3. ABG: hypoxia, hypercarbia, metabolic acidosis
Chest x ray, CT Scan
I. Air filled pleural space, new air fluid level
II. Shifting of trachea, collapse of lung
III. Reducing fluid level o serial chest x ray following pneumonectomy
a) Brochography, sinogram: confirmatory test
b) Bronchoscopy
c) Accumulation of radionuclide In pleural space after inhalation of xenon or O2-N2O
mixture.
d) Methylene blue injection into pleural space and recovering it In sputum.

22. PREMEDICATION
1. Informed consent.
2. Npo orders.
3. Premedication is not required in emergency surgery.
4. Diazepam 5mg per oral, Midazolam can be used.
5. Inj Glycopyrrolate 10mcg/kg IV .
6. Anti aspiration prophylaxis if awake intubation is planned.

23. MONITORING
 Pulse oximetry
 Capnography
 ECG
 Blood pressure preferably IBP
 CVP, urine output
 Temperature

24. POSITIONING
I. Lateral decubitus position
II. Lung with BPF placed in non dependent position(on upper side)

25. Induction and Intubation
 100% oxygen with facemask of appropriate size
 Sitting up position is preferred pre induction to prevent spill over
 Priority is to isolate affected site in terms of contamination and ventilation
 Endobronchial tube placed before PPV initiated
Care of ICD :
Chest tube position in infected area confirmed
Chest tube has to be left unclamped to :
1 . Avoid any bouts of coughing
2. Prevent build up of tension pneumothorax in case a pre existing valve
mechanism exists
During induction,suction from chest tube is avoided to prevent loss of tidal volume
.

26. Choice of ETT:
Single lumen ET tube can be used for small sized BPF
Double lumen tube for larger size BPF
Intubation techniques:
1. Awake intubation off an anesthetized airway:
- Done with help of fibreoptic bronchoscopy and DLT
- Is safe and most ideal technique
- Neuroleptanalgesia with topical airway anesthesia may be required
2. Intubation after deep anesthetic plane:
- Done with patient breathing spontaneously
- Using IV Propofol 2mg/kg or Thiopentone 5mg/kg

27. Ventilator management is difficult because
• Positive pressure ventilation may lead to tension pneumothorax
• Air leak from the fistula can lead to inadequate oxygenation and ventilation
•A chest drain can reduce the chance of tension pneumothorax with PPV.
• High frequency jet ventilation with permissive hypercapnia avoids the need for a
DLT or SLT with blocker. HFJV avoids barotrauma to the other lung and
decreases the air leak.
• If high frequency jet ventilation is not available, BP fistula is one of the strict
indications for split lung (i.e. DLT) ventilation.

28. 3.Rapid sequence intubation:
- Done with IV succinyl choline
- Has increased risk of tension pneumothorax and contamination
4.Once tube is adequately positioned in trachea, there may be outpouring of pus
from tracheal lumen
5.Thus ,this lumen should be immediately suctioned with a large bore catheter
6. Fibre optic intubation of double lumen tube / SLT is preferred in post
pneumonectomy patients, with tip of endobronchial lumen placed in existing lung

29. Maintenance
1. Nitrous oxide avoided
2. Oxygen + Air + Isoflurane / Sevoflurane used
3. Fentanyl + Vecuronium intermittent boluses
4. High frequency oscillatory ventilation
- May be used along with Permissive hypercapnia
- Minimizes air leak and also stabilizes hemodynamic
- Especially used in patients with multiple BPF
5. After chest is opened, if excessive air leak is encountered, when using SLT,
ventilation can be improved by lung packing and Manual control of air leak

30. Extubation
 Early extubation is preferred
 This is to avoid barotrauma to surgical stump from PPV
 Extubated fully awake, warm and fully reversed
Post operative management
 Change DLT to SLT
 Shifted to ICU in sitting position after establishment of spontaneous ventilation
 Respiratory failure is common post operatively in these patients

31. POSTOPERATIVE CONSIDERATIONS
COMPLICATIONS
1. Atelectasis
2. Pneumothorax
3. Cardiac Herniation
4. Haemorrhage
5. Arrhythmias
6. Right heart failure

32. Postoperative Analgesia
Thoracotomy is among the most painful of all operative procedures.
1. Systemic opioids
2. NSAIDS
3. Epidural analgesia
4. Intercostal nerve blocks
5. Inter pleural analgesia
6. Cryo-analgesia

33. Conservative management of BPF
BPF can be conservatively managed if small, adequately ventilating them and giving
antibiotics
Ventilatory strategies:
- One lung ventilation:
 Bronchus of normal lung intubated and ventilated
 This allows BPF to rest and heal with the help of antibiotics
 This may lead to an intolerable intra pulmonary shunt
 PEEP may be needed to maintain PO2
- Differential lung ventilation:
Each lung is managed with different types of ventilation
Done through DLT and two synchronized ventilators

34.  Healthy lung is ventilated with normal ventilator
 Affected lung is exposed to smaller tidal volumes or HFJV
 CPAP with oxygen at pressures below the critical opening pressure of the BPF
can be used
 Critical opening pressure is determined by assessing lowest level of CPAP
which must be applied to the bronchus on affected side to produce continuous
bubbling through the underwater seal.
High frequency jet ventilation:
 Used for larger BPF or multiple BPF
 This causes minimal gas loss through fistula as VT is low
 Thus ,BPF may heal more quickly
 Also ,hemodynamic affects are usually minimal

35.  Unidirectional Chest Tube Valve:
 Usually ,inspiratory cycle of ventilator triggers closure of chest tube valve
 Valve again opens during expiration
 This reduces gas flow across BPF during PPV
 Flow across fistula is reduced by increasing pleural pressure during positive pr
essure breaths
 This reduces the pressure gradient across BPF
 Other strategies:
 PEEP to pleural cavity equalising with intrathoracic PEEP
 If disruption occurs early in the post pneumonectomy patients, re-suture stump
 Small fistulas can be closed by bronchoscopy or fibrin glue

36. Spirometry
Spirometry should be performed on all patients undergoing lung resection. Provided
the patient effort is adequate, the presence and severity of obstructive and restrictive
lung disease can be reliably identified.
The following parameters have been associated with an increased risk of pulmonary
complications following pneumonectomy:
FVC <50% of predicted or <1.75-2L
FEV1>2L, mortality = 10%, <2L, mortality = 20-45%
MBC <50-60% of predicted, mortality = 5-32%
An FEV1 of less than 800ml generally precludes thoracic resection apart from lung
volume reduction surgery
The response to bronchodilators should be assessed in patients with obstructive
airways disease.