Bronchopleural fistula Sudhir Rao Respiratory

What ? How ? Communication between the bronchial tree and the pleural space Common aeitiology- pulmonary resection lung necrosis complicating- infection chemotherapy radiotherapy persistent spontaneous pneumothorax tuberculosis lung neoplasm blunt & penetrating lung injuries chest tube drains/ thoracocentesis

Risk factors, incidence & mortality Peri-operative risk factors- Pre- operative- fever, steroid use, Haemophilus infuenzae in sputum. Elevated ESR & anemia Post-operative- fever, steroid use, pre-operative chemo-radiotherapy, leukocytosis, tracheostomy & bronchoscopy for mucus plugging Other- residual tumor at the resection margins, long bronchial stump, tightness of sutures, excessive peribronchial and paratracheal dissection, ARDS, invasive chest procedures & underlying debilitating disorders ( diabetes, malnutrition, pneumonia, lung abscess, severe COPD with bullous disease) Incidence- Following pulmonary resection- 2-5% (< 1% after lobectomy; < 12.5% after pneumonectomy) Almost always occur within 3 months after surgery Mortality rates – 18- 67%; Most common causes- aspiration pneumonia & subsequent ARDS tension pneumothorax

How do they present? Acute- sudden SOB, BP subcutaneous emphysema cough with expectoration of purulent material and fluid persistent air leak  or disappearence of pleural effusion on Chest X-ray (in Post-operative cases) Subacute- wasting, malaise, fever and cough Chronic- (usually associated with an infectious process)- there is fibrosis of pleural space and mediastinum, typically preventing mediastinal shift

Diagnosis Bronchoscopy- Direct visualization Selective bronchography Instillation of methylene blue Capnography to identify the bronchial segment related to BPF[ end tidal CO2 is measured by connecting a capnograph to a polyethylene catheter passed through the bronchoscopic channel- absence of capnographic tracing suggesting communication to air, suggests BPF { disconnect chest tube from UWSD} CT scan- to identify underlying cause CT bronchography- injecting 20-30ml Omnipaque into suspected fistula site Ventilating scintigraphy using 133Xe as the preferred agent [sensitivity 83%, specificity 100%]

Management Adequate pleural drainage & placing patient with the affected side down Air-leaks range <1-16l/min requires large-bore chest tube (e.g a 32F tube) Major stump dehiscence- immediate resuture and reinforcement of the bronchial stump Treatment of infection Proper nutrition Surgical closure successful in 80-95% Surgical techniques- Chronic open drainage Direct stump closure with intercostal muscle reinforcement Omental flap Trans-sternal bronchial closure Thoracoplasty with or without extrathoracic chest wall muscle transposition

Non-surgical management In spontaneous primary or secondary pneumothorax with persistent leak- observe for 4 days for spontaneous closure if air-leak persists for > 4 days – surgical closure indicated additional chest-drain or  of suction pressure NOT indicated Patient’s condition too poor for surgery Small fistula (3-5mm diameter) Bronchoscopic treatment with fistula closure successful > 1/3 rd of patients Sealing compounds – lead shot, absolute alcohol, polyethylene glycol, cyano-acrylate glue, fibrin glue, blood clot, antibiotics (tetracycline, doxycycline), albumin glutaraldehyde tissue adhesive, cellulose, gel foam, balloon catheter occlusion, silver nitrate, calf bone etc. Intra-bronchial valves, vascular embolisation coils Stents Watanabe Spigots

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