BPF

1. Bronchopleural
Fistula

2. Definition
 A bronchopleural fistula (BPF) is a
communication between the pleural space and
the bronchial tree.

3. Aetiology
 Bulla
 lung abscess/necrotizing pneumonia
 Neoplasms
 peripheral bronchiectasis
 trauma
 Postoperative e.g. pneumonectomy
 Ventilator induced lung injury

4.  Persistent air leak
>24 hs ( VILI )
 Postoperative
 Air fluid level

5.  precise measurement of the leak is not necessary
 For clinical purposes, there are three levels of severity
of leakage from a BPF:
• Bubbling only during inspiration.
• Bubbling that continues during both inspiration and
expiration
• A leak of sufficient magnitude (ie, greater than 100 to
150 mL per breath) so that differences in inspired and
expired tidal volumes can be detected at the ventilator,
using an appropriate correction for compressible
volume.

6. Adverse effects of a BPF
 incomplete lung expansion; atelectasis, V/Q
mismatch ( large leak, restictive lung dis)
 effective TV; ( compensation exacerbate the
problem)
 respiratory acidosis ( usually due to severity of
underlying lung disease)
 loss of PEEP
 pleural disease infection
 factitious ventilator cycling

7. Managment
 Conservative
 Endoscopic
 surgical

8. Conservative
 Drainage of the pleural space
 treatment of infections
 optimizing nutrition
 Ventilator management

9. Ventilator management
 A BPF may be more likely to develop and persist in the
presence of a large pressure gradient between the
airways and the pleural space (or the airways and the
chest tube, once a pneumothorax develops).
 ventilator management should include decreasing
airway pressures as much as clinically feasible and
reducing chest tube suction to the lowest level that
maintains complete lung inflation.

10.  Measures directed at reducing the leak itself (as
opposed to therapy for the underlying disorder) seldom
make much difference in the patient's clinical course.
Even when leaked volume can be reduced, there tends
to be little if any effect on gas exchange, as measured
by arterial blood gases.
 In ARDS, the CO2 content of the leaked gas is usually
similar to that of gas exhaled via the endotracheal tube,
indicating that this gas participates in gas exchange and
is not "lost" or "wasted" volume

11.  Wean early
 Partial ventilatory support
 Avoid hypocapnia
 Consider permissive hypercapnia
 Reduce insp time ( MAP) I:E = 1:3; PFR = 70-100,
no pause
 Effective TV = 5-8 ml
 Minimal PEEP
 Least ICT suckion
 If movement increase leak, sedation
 Possition difference
 Treate bronchospasm
 Treate the cause of respiratory failure

12.  independent lung ventilation
 high-frequency ventilation
 inspiratory chest tube occlusion
 application of PEEP to the chest tube

14. bronchoscopic techniques
utilizing the fiberoptic bronchoscope include first
identifying the affected bronchus and then occluding it
with one of the following:
 A balloon (using a Fogarty or Swan-Ganz catheter).
 A plug composed of Gelfoam, fibrin, or tissue glue.
 Local application of silver nitrate
 Local injection of polidocanol sclerosants
 Coagulation of the leaking site with the Nd:YAG laser.

15.  Methylmethacrylate
 injection of absolute ethanol
 endobronchial silicone plugs,
 gluteraldehyde tissue adhesive
 lead plugs
 endobronchial valve
 Success with any of these methods is likely to be
dependent on the patient receiving treatment as well as
the skill of the bronchoscopist .

16. postpneumonectomy
 Necrosis of bronchial stump
 Dehiscence of suture line
Clinical
 Sudden onset of dyspnea
 Expectoration of bloody fluid
Imaging findings
 Return to midline of a previously shifted mediastinum
 A drop in the fluid level by more than 2 cm is abnormal