Bronchopleural fistula is an abnormal connection between the bronchial tree and pleural space. It most commonly occurs after pulmonary resection surgery, with reported incidence rates of 1.5-28%. Patients at higher risk include those with lung infections, trauma, or underlying lung disease. BPFs are classified as acute, sub-acute, or chronic depending on time of onset and presentation. Acute BPF presents urgently with breathing difficulties while chronic BPF involves infection and fibrosis. Treatment involves managing life-threatening complications, controlling infections, and closing the fistula through surgery or drainage.

2. INTRODUCTION
• Bronchopleural fistula is defined as a
communication involving both the pleural space
and the bronchial tree.

3. ETIOLOGY
• The most common manifestation of BPF is in the
postoperative phase following any pulmonary
resection.
• The incidence of BPF has been reported from
1.5 to 28% after pulmonary resection.

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 This most common manifestation is followed by:-
• lung necrosis
• persistent spontaneous pneumothorax
• chemotherapy or radiotherapy, (as a treatment
for lung cancer)
• tuberculosis

5. RISK
• Patients at risk for the development of BPF
include patients with:-
 ARDS
 chest trauma
 invasive chest procedures
 debilitated patients
 patients with pneumonia

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 lung abscess
 COPD
 bullous lung disease
 spontaneous pneumothorax
 parenchymal abnormalities

7. CLASSIFICATION
Postoperatively a BPF may be classified as:-
• Acute
• Sub acute
• Chronic
 The acute form of BPF is typically related to
stump dehiscence and necessitates early re-
operation.

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 The sub-acute and chronic forms are
commonly associated with infection and
immunocompromised or debilitated patients with
various comorbidities.

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• Varoli et al7 classified fistulas according to
the time of onset after the operation:
1) early [1 to 7 days]
2) intermediate [8 to 30days]
3) late fistulas [more than 30 days].

10. CLINICAL FEATURES
The Acute BPF : It is a life-threatening condition
due to tension pneumothorax or asphyxiation
secondary to massive pulmonary flooding.
 The clinical presentation may be
characterized by:-
• the sudden appearance of dyspnea
• hypotension
• Subcutaneous emphysema and purulent cough.
• There may be an attendant acute tracheal shift.

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• An acute presentation generally requires a
visit to the operating suite and should be
treated as quickly as possible.

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The Sub-acute presentation: It is rather
insidious and is characterized by:-
• a general wasting
• malaise
• fever
• minimally productive cough.

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The chronic form of BPF: It may be associated
with an infectious process and there may be co-
attendant fibrosis of the pleural space and
mediastinum.

14. DIAGNOSIS
• methylene blue test
• Bronchography
• CT-scan to diagnose the etiology
of bronchopleural fistula.

15. INVESTIGATIONS
• Chest x-ray
• Bronchoscopy
• Biopsy
• Routine examination:-
 Blood grouping and crossmatching
 Serology
 CBC

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 sugar
 urea
 creatinine
 serum

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 amylase
 Electrolytes
• Urine RE/ME
• ECG

18. COMPLICATIONS
• Tension pneumothorax
• Infection
• Medistenitis
• Inflammation
• Subcutaneous emphysema

19. TREATMENT
• Surgical and Medical treatment are the two
options as per the clinical condition of the
patient.
1) The control of any life threatening complication
like tension pneumothorax by emergent
drainage is required.
2) In some life threatening conditions, airway
control and postural drainage by placing the
affected lung down is required.

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3) If bronchiat stump dehiscence is suspected,
then immediate reexploration and resuturing
with reinforcement is suggested.
4) Management of the underlying co-morbidities,
and conditions should be initiated immediately to
control BPF.
5) If infection or empyema is suspected, it requires
proper management with antibiotics and
drainage if necessary .

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6) Closure of the fistula with vascularised tissue
and obliteration of the chest cavity contributes to
the success of the treatment.
7) Chest tube insertion: in cases of high flow BPF
and Empyema.

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8) Mechanical ventilation:-
• Bronchopleural fistula is an area of low
resistance, hence along with continuous air leak,
it not only delays the healing of the fistulous tract
but also reduces the tidal volume and affects
minute ventilation and oxygenation.

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a) Mechanical ventilation helps to limit the amount
of PEEP during ventilation which also reduces
the airway pressure and flow through the
fistulous tract and prevents the loss of tidal
volume.
b) Selective single lung ventilation of unaffected
side or differential lung ventilation with double
lumen tube has also proved beneficial to some
extent.

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c) High frequency ventilation is used only with
proximal BPF and when the lung parenchyma is
normal.

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9) Surgery
10) Bronchoscopy

26. Fig:Management of bronchopleural
fistula.

27. REFERENCE
• Das.S, Manual on clinical surgery including
special investigations and differential diagnosis,
4th edition, 13, Old Mayors’ Court, Culcutta.
Page no 305
• Hauser.kasper, Longo Braunwald, Jameson
Fauci, Harrison’s, Principles of Internal
Medicine, 16th edition, volume 1, McGraw-Hill,
Medical Publishing Division, New York. Page no
1497-1507
•
•

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• Arnold Hodder, Williams Normans, Bailey and
Love’s Short practice of surgery, 25th edition.
Page no 891.
• Retrieved from www.google/bronchopleural
fistula .com