A 15-year-old male was brought to the emergency department 19 days after sustaining a chest injury from a tractor steering wheel. He had pain and breathlessness after the injury and was found to have a near complete transaction of the right main bronchus with bronchopleural fistula (BPF). On examination, he had absent breath sounds on the right side and a chest tube draining fluid. A CT scan showed a right pneumothorax with collapsed lung. BPFs can be classified based on their airflow patterns and location. Treatment depends on the size and chronicity of the fistula and includes medications, endobronchial techniques, surgery, or a combination. The goal of anesthesia management is to optimize

1. Presenter: Dr Andal Priyanka
Moderator: Dr. Pratiti

2.  A 15-year-old male, weighing 49 kg was
brought to the emergency Department 19 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 & on fiberoptic bronchoscopy near
complete transaction of right main bronchus
with bronchopleural fistula.

3.  0/E:conscious, GCS – 15/15. PR =92 beats/min,
BP= 120/76 mmHg, RR 19/ min and SPO2was 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(pH=
7.46, PCO2 =37, PO2 = 70, HCO3 =26.8,BE= 2.5).
Chest radiograph and Computed Tomography (CT)
Scan showed right sided pneumothorax with
collapsed lung, absent bronchopulmonary
markings with ICD in situ

4. A Broncho pleural fistula (BPF) is a communication
between the pleural space and the bronchial
tree

6.  ALVEOLOPLEURAL FISTULA(APF): Pulmonary pleural
communication distal to segmental bronchus and
pleural space.
 Common after lung resection except pneumonectomy
 BRONCHOPLEURAL FISTULA: Communication between
mainstem, lobar or segmental bronchus or the pleura
lined cavity
*Pleural disease by Richard Light 6th edition
Anesthesia for thoracic surgery – Slinger P

7.  Continuous (C): largest, uncommon Eg: BPF on MV
 Inspiration(I): second largest, Eg: APF, small BPF on MV
 Expiration(E): after lung surgery suggestive of APF
 Forced Expiration(FE): Eg: coughing, common after
lung resection
HEALING
*Pleural disease by Richard Light 6th edition
C I E FE

8. POSTOPERATIVE
 Incidence 1.5 to 28% for pnemonectomies (2% -
11%) and for lobectomies (0.5%)
 Mortality: 5% to 70%
 Risk of dehiscence* :
 1.8% : manual suture
 5.0% : stapling device
 1.9% : reinforcement suture at distal side
 1.0% : reinforcement suture at proximal side
*Sonobe et al. Eur J Cardiothorac Surg 2000; 18:519–523

9.  Advanced case ( main bronchus)
 Previous ipsilateral thorocotomy
 H/O chemotherapy and radiotherapy
 H/O fever, steroid, diabetes
 Anemia, leukocytosis, ESR, hypoalbuminemia
 Residual tumor on stump
 Excess peribronchial, paratracheal dissection
 Intrathoracic chemotherapy
 Tightness of sutures
 Continous Mechanical ventilation > 24hrs
*Sato et al. Nippon Kyobu Geka Gekkai Zasshi 1989;37:498–503

10.  Infection: bacterial , fungal , parasitic
 Spontaneous rupture of bullae, cyst
 After procedures
 Persistent spontaneous pneumothorax.
 Thoracic trauma
 Erosion of bronchial wall : by malignancy,
foreign body, chronic inflammation
 GERD

11.  Varoli et al* classified according to time of onset
Early- 1 to 7 days
Immediate – 8 to 30 days
Late- more than 30 days
 Usually presents after 7-15 days following lung
resections
 Early indicators- reappearance of fever, increased
cough with purulent or serosanguinous sputum
*Varoli F et al. Endoscopic treatment of bronchopleural fistulas. Ann Thorac Surg 1998;65:807-9.

12. Life-threatening , due to tension pneumothorax or
asphyxiation secondary to massive pulmonary flooding,
Clinical presentation
 sudden onset of dyspnoea,
 hypotension,
 subcutaneous emphysema, cough with expectoration,
There may be antecedent tracheal shift
Acute form is typically related to stump dehiscence &
requires immediate re-exploration.

14.  Ass infection, I/C
state
 Generalised wasting
 Malaise
 Fever
 minimally productive
cough
 It may be associated with
an infectious process and
there may be coexistant
fibrosis of the pleural
space and mediastinum
**

15.  CLINICAL
 After pneumonectomy- development of sudden
onset dysponea, subcutaneous emphysema
 After lobectomies - persistent air leak, purulent
drainage and expectoration of purulent material
 After ICD removal – fever, purulent sputum,
new air fluid on CXR

16.  CXR
 Steady increase in intra pleural space
 Appearance of new air fluid level(indicates
level of BPF)
 Drop in air fluid level more than 2cm(in
absence of chest tube)
 Development of tension pneumothorax

18.  Evaluation & localization of fistula
 Instillation of methylene blue through bronchoscope – appearance of
dye in chest drain, sputum
 Visualisation of continuous return of air bubbles on bronchial wash
 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
 Introduction of sealants into the fistulous tract

20.  CT scan
 Ventilation scintigraphy
 CT Bronchography
 Chest tube

21. ARDS
Aspiration
pneumonia
Tension
pneumothorax
SURGICAL MEDICAL
early & large
postoperative fistula
chronic & small fistula
associated with infections
MORTALITY
1 2 3

22. •ANEMIA
•HYPOPROTEINEMIA
•NUTRITION
•INFECTION
•COMORBIDITIES
•PULMONARY FLOODING
•HEMODYNAMICALLY
UNSTABLE WITH RF
•PNEUMOTHORAX
•EMPYEMA
•HIGH FLOW BPF
CHEST DRAIN
MECHANICAL
VENTILATION
NUTRITIONAL &
PHYSICAL
REHABILITATION
APPROPRIATE
MEDICATION

23. Indications
 High flow BPF
 Drainage of empyema
 Pneumothorax
Advantages
 Add positive intrapleural pressure during expiration to reduce
air leak and maintain PEEP
 Intermittent occlusion during inspiratory phase to decrease
BPF flow
 Useful in ARDS
 Chest tube can be used for pleurodesis

24. Disadvantages
 Can function as foreign body and delay healing
 Predispose to infection at insertion site and pleural space
 Loss of tidal volume
 Abnormal gas exchange
 Inappropiate ventilator cycling
• FANNING EQUATION
• Larger diameter for drainage of air
Size of tube

26.  1977 - Ratliff et al pioneered endoscopic
management of BPF
INDICATIONS
 Suitable for small fistulas(<5mm).
 Proximally located fistulas- main stem, lobar,
or segmental bronchi are more suitable.
 Useful for patients who are not proper
candidate for surgery.

27.  Injecting absolute ethanol
directly into submucosal
layer of a fistula is first-line
therapy for patients with a
postoperative central BPF
with an orifice < 3 mm
 Lead Shots
 Polyethylene Glycol
 Cyanoacrylate Glue , Fibrin
Glue , Blood Clot
 Antibiotics
 Albumin-Glutaraldehyde
Tissue Adhesive
 Gel Foam
 Coils
 Intrabronchial stents, valves
 Calf Bone
 Balloon Catheter Occlusion
 Cellulose, silver nitrate
*Kinoshita et al. Chest 2000; 17:790–795
*Potaris et al Med Sci Monit 2003; 9:P179–P183
*Chest 2008; 133(6): 1481-4

30.  Revision of bronchial stump (CLAGETT procedure)
 Decortication of lung
 Closure of fistula with muscle flap from intercostal space
 Thoracoplasty with pedicle muscle flap to cover bronchial stump.
 Resection of diseased chronically infected segments
 First stage: chest cavity drainage consisting of muscle flap operation
 Second stage: After aggressive nutritional & physical rehabilitation,
second procedure for chest cavity obliterationwith an omental flap is
performed
*Turk et al. Plastic Surg 2000; 45:560–564

31.  HISTORY
 EXAMINATION
Estimation of volume loss through fistula
1. Check bubble flow through chest drain- continous (large) or
intermittent (small)
2. Quantification of size of BPF- Difference of inhaled vs exhaled tidal
volumes
 Intubated patients: direct attatchment of spirometer to ETT tube
 Non intubated patients: tight fitting mask and fast responding
spirometer

32.  Routine – CBC, RBS, SE, KFT, LFT, Coag profile
urine r/m, CXR , ECG, ECHO
 Specific – ABG, Bronchoscopy, CT, VS

33.  Optimize respiratory function(smoking, infection)
 Optimize associated diseases
 Predict difficult endobronchial intubation
 Predict desaturation during OLV
 If chest tube present- check for patency
 Mild sedation
A
B
C

34. •BPF planned
non thoracic
surgery
REGIONAL
•Planned
surgery for
BPF
Elective
BPF surgery
•BPF with life
threatening
complications
Emergency
BPF surgery

35. PATIENT
• Diseased lung( air leak, pneumothorax, soilage, V/Q
mismatch)
• Elderly , comorbidities
SURGERY
• Open chest,
• Bleeding
ANESTHESIA
• Position
• Mechanical ventilation
• OLV & HPV
• Blood loss
• Diseased lung
• Chest tube
• Choice of anesthetic & CO
•Temperature
• Fluid
• Emergence
• Post op icu stay
•Pain control
•Mortality

36.  ASA I
 ASA II – ECG , SpO2, NIBP,
EtCO2, Temperature
 urine output.
 Thoracic surgery:
(Paw)
1) Arterial line - IBP
2) central line
3) side stream spirometry (NR)
4) TEE
5) EDU
*Hemodynamic monitoring in thoracic surgery – Jacob Raphael 2017

37. Oxygenation
and
ventilation
Tension
Pneumothorax
Soiling
Air leak
*James Mitchell (December 24, 2003)
Avoid CMV
Avoid
clamping drain
Avoid CMV
Avoid CMV
Avoid suction
to drain
Isolate
lung
ASAP!!
!

38. Position for induction- Head up with 30 degree lateral tilt keeping
diseased lung down
Options to secure airway include
1)Awake fibreoptic intubation with DLT,- Induction of GA once lung
isolation achieved
 Safest but technically difficult
 Requires patient cooperation and thorough airway topicalization
2) Induction of GA maintaining maintaining spontanoeus ventilation,
DLT insertion when deep , aviod IPPV
3) If airway thought to be easy, Modified RSI can be done avoiding IPPV
until lung isolation achieved
Thoracic epidural + IV sedation
(SLT safe to use: if fistula small, chronic, uninfected)
* Anesthesia for thoracic surgery – Slinger P

40. Air leak
Loss of TV, PEEP
V/Q mismatch
Incomplete lung expansion
CO2 retension
Auto trigger
Paw < Critical opening
Pressure
Pleural decompression for
lung expansion GOALS
CHALLENGES

41. To keep reduced airway pressures
 Low tidal volume
 Limiting PEEP
 Short inspiratory time ( high PIFR)
 Reducing respiratory rate
 Reducing minute ventilation
Pleural decompression
Chest drain: lowest possible suction pressure or
no suction as increased suction pressure increases
the flow.
For large fistula: Independent lung ventilation or
HFJV can be considered
*Pierson DJ. Management of bronchopleural fistula in patients on mechanical ventilation.

42. Chest tube manipulation
 Intermittent inspiratory chest tube occlusion
 Application of intrapleural pressure at expiration
Independent lung ventilation
• CPAP
• High frequency ventilation
Extracorporeal oxygenation
• HFPPV
• HFJV
• HFOV
• HFFI
• HFPV
HFV

43. PaO2 PCO2
TV
RR
MAP
High
PEEP
•Small tidal
volume
•Lower
airway
pressure

44.  Longitudinal gas
transport :
 Coaxial flow
 Molecular diffusion
 Mixing of fresh & exhaled gas :
 Lateral diffusion
 Turbulent flow at airway bends
& bifurcations
 Intra-alveolar pendelluft
 Heart beat
 Most proximal alveoli by bulk
flow
Suboptimal humidification
•Inspissation of airway secretions
•Necrotizing tracheobronchitis
Gas trapping
COMPLICATION WITH HFV

45.  50%
 Stimulus : PAO2
 Inhibitors :
 Infection
 Vasodilators
 Hypocarbia
 Hypothermia
 Inhalational
 Surgery
* Miller 8th Edition

46.  Inhalational agents and narcotics or epidural
 High FiO2
 IPPV to healthy lung
 Ventilate healthy lung with normal tidal volume.
 Ventilate affected lung with smaller volume
 Titrate ventilation to normal PaCO2
 Blood loss
 Fluid management
EMERGENCE : Avoid high Paw ( SIMV, Hand ventilation)
Examine airway – suction , extubation
*Thoracic surgery -James Mitchell (December 24, 2003)

47.  CVP
 SPV
 SVV
 PPV
 EVLW
 CO
 CI

48.  Assesed EVLWT, PaO2/FiO2,blood lactate,ScvO2,BE,CVP,CI,GEDI
Carbohydrate
drink
BSS 3-4ml/kg/hr
vasopressor
Meta analysis
have shown
that GDFT is
better than
conventional

49.  Thoracotomy – 80%
a. Atelectasis
b. Pneumonia
c. RF
d. DVT
Types
1) Acute
2) chronic
Thoracotomy T4 – T6
CHEST DRAIN T7 – T8
MEDIASTINAL PLEURA X
CENTRAL DIAPHRAGMATIC
PLEURA
C3 – C5
I/L SHOULDER PAIN BRACHIAL
PLEXUS

50. Thoracic epidural
Paravertebral block
Intrathrecal catheter
Intercostal nerve block
Inter pleural block
 Opioids
 NSAIDS
 ketamine
 Dexmed
 Gabapentin
*Post thoracotomy pain management - Kathrine
LOCAL
ANESTHETICS OTHERS
Cryoablation
TENS