1. Management of Bronchopleural Fistula 氣管肋膜廔管
Dr Grace SM Lam
ICU Friday Lecture
16th January, 2009
支气管胸膜瘘

2. Bronchopleural Fistula
Communication between the bronchial tree & pleural space
Mortality varies between 18-67%
Aetiology
Postoperative 2/3
Non-postoperative 1/3

3. Post-operative BPF
Most commonly follows pneumonectomy (0-9% v 0.5% in lobectomy)
Predisposing factors:
Rt pneumonectomy (shorter Rt main bronchus & single Rt bronchial artery)
Uncontrolled preoperative pleural /pulmonary infection
Preoperative irradiation
Trauma
Postoperative positive pressure ventilation
Faulty closure of bronchial stump

4. Post-pneumonectomy CXRs
Day 2
Day 14
Day 1
Day 30
Serial radiologic changes seen after pneumonectomy
Radiographics 2006;26:

5. Acute Post-pneumonectomy BPF
Day 22
Tension pneumothorax & Pulmonary flooding
Reappearance of air OR a drop in air-fluid level >1.5cm
Mediastinal shift
Subcutaneous or mediastinal emphysema
Contralateral lung consolidation from transbronchial spill
Radiographics 2006;26:

6. Non-postoperative BPF
Causes:
Necrotizing pneumonia, TB, lung abscess & empyema
ARDS
Persistent spontaneous pneumothorax
Thoracic trauma
Iatrogenic (line placement, pleural biopsy, FOB)
Irradiation & chemotherapy

7. Clinical Presentation
Persistent air leak >24 hours after the development of pneumothorax
Exclude other causes of persistent air leak
An external air leak
Extra-thoracic location of side holes
Disconnections

8. Clinical Presentation
Acute
Sudden SOB, hypotension, coughing up of fluid & blood
Subacute
Insidious onset with fever, wasting, minimally productive cough
Chronic
Fibrosis of pleural space prevents mediastinal shift

9. Diagnosis
Clinical
Instillation of methylene blue through stump followed by its detection in chest tube
Inhalation of different concentrations of oxygen and N2O followed by changes in gas concentration in post-pneumonectomy space
CT scan to delineate the aetiology
Bronchoscopy is both diagnostic & therapeutic

10. General Management
Drainage of pneumothorax & infected pleural space with appropriate size chest tube(s)
Pulmonary flooding: Airway control & position affected lung down
Treat underlying cause, especially infection
Maintain nutritional status
Flow through a tube varies exponentially with the radius of the tube
Flow varies with the 5th order of the tube radius in clinical situations due to turbulent flow of moist air (Fanning equation)

11. Mechanical Ventilation
BPF offers a pathway of least resistance (or high compliance)
Potential problems
Significant loss of tidal volume (VT)
↓ CO2 excretion
↓Utilization of inspired O2
Failure to maintain PEEP
Air flow through fistula delays healing
Inappropriate cycling of ventilator

12. Conventional Ventilation
Goal is to maintain adequate ventilation & oxygenation while↓fistula flow
Minimize the pressure gradient between airway & pleural space
Minimize mean airway pressure
Lowest effective tidal volume
Shorten inspiratory time
Least number of mechanical breaths
Limit PEEP
Discontinue /minimize suction on chest tubes

13. Chest 1986; 90:
Persistent Bronchopleural Air Leak During Mechanical Ventilation. A Review of 39 Cases.
A retrospective review
Jan 1977 – Dec 1980
County hospital and regional trauma & burn center in Seattle
Consecutive patients who received mechanical ventilation & developed persistent air leak >24hrs
Patients after cardiac surgery or pulmonary resection were excluded

14. Non-traumatic Surgical Illness
Chest 1986; 90:
Received MV
1700
Persistent Air Leak
39 (2%)
Trauma 27 22
Chest
Non-chest 5
Non-traumatic Surgical Illness 4
Abdominal 2
Burn
Medical Illness 8
Pneumonia 4
TB 1
Near-drowning 1
Pancreatitis 1
Sepsis 1

15. Chest 1986; 90: 321-323 Overall mortality 67% Increased mortality in:
Late air leak (94% v 45%; P=0.002)
Diagnoses other than chest trauma (P<0.005)
Maximum air leak >500ml/breath (100% v 57%; P<0.05)
Pleural space infection (87% v 54%; P<0.05)
Late air leak defined as air leak first appearing after 24hours after admission.

16. Chest 1986; 90:
Mode of MV
Assist-control ventilation 33
Intermittent mandatory ventilation 6
Only 2 patients had persistent acidemia PH<7.30 despite adjustment of ventilatory settings
BPF can usually be managed by conventional ventilation.
The need for special ventilation techniques is uncommon.

17. Failure of Conventional Ventilation…
Options:
Chest tube manipulation
Intermittent inspiratory chest tube occlusion
Application of intrapleural pressure at expiration
Independent lung ventilation
High frequency ventilation
Extracorporeal oxygenation

18. Intermittent Inspiratory Chest Tube Occlusion
Synchronizing chest tube occlusion at inspiration
Limit loss of tidal volume on inspiration
Restores pulmonary gas exchange & promotes healing of BPF
During Inhalation
During Exhalation
Chest 1990; 97:

19. Independent Lung Ventilation
Indication
Anatomical lung separation
Massive hemoptysis
Whole lung lavage for pulmonary alveolar proteinosis
Copious secretions (e.g. bronchiectasis, lung abscess)
Physiological lung separation
Unilateral parenchymal injury
Aspiration
Pulmonary contusion
Pneumonia
Unilateral pulmonary edema
Single lung transplant (post operative complications)
Bronchopleural fistula
Unilateral bronchospasm
Severe bilateral lung disease failing conventional ventilationa
Crit Care. 2005; 9(6): 594–600

20. Methods of Lung Separation
Endobronchial Blockers
Double Lumen ETT

21. Methods of Lung Separation
Endobronchial Blockers
Can be passed
Along the side, or
Into the lumen
Of the single lumen ETT
Final placement requires bronchoscopic guidance
Does not allow ventilation of the obstructed lung (for anatomical lung separation)

22. Methods of Lung Separation
Double Lumen ETT
For independent lung ventilation

23. Size of double lumen ETT
Appropriately sized to allow:
Adequate functional separation of the lungs
Access for suctioning and bronchoscopy
Prevent migration of the tube
Tube size (F)
Circumference (mm)
Lumen diameter (mm)
Indication 35
38.0
5.0
Pediatrics 37
40.0
5.5
Small adults 39
44.0
6.0
Medium adults, usual female size 41
45.0
6.5
Large adults, usual male size

24. Double Lumen ETT Placement
Confirming position by ascultation following sequential clamping is inaccurate in 38%
Bronchoscopic confirmation is recommended
For a left-sided double lumen ETT, bronchoscopy via:
Tracheal port ~ Carina visualized, without herniation of bronchial cuff
Bronchial port ~ LUL orifice visualized

25. Independent Lung Ventilation
For unilateral BPF
Unaffected lung:
Conventional ventilation
Affected lung:
Conventional ventilation with lower mean airway pressure
CPAP at pressure just below the critical opening pressure of BPF
High frequency ventilation

26. High Frequency Ventilation
High frequency oscillator

27. High Frequency Ventilation
Conventional Ventilation
High Frequency Ventilation
Gas transport occurs by bulk flow /convection & molecular diffusion
VA = f (VT – VDS)
Delivery of small tidal volumes (VT≦VDS) at supra-physiologic frequencies
Governs lung volume & oxygenation
Frequency
Tidal volume & CO2 elimination

28. Gas Transport in HFV Longitudinal gas transport :
Coaxial flow
Molecular diffusion
Mixing of fresh & exhaled gas :
Lateral diffusion
Turbulent flow at airway bends & bifurcations
Intra-alveolar pendelluft
Most proximal alveoli by bulk flow

29. HFV in BPF Flow through an air leak is proportional to:
Cross-sectional area of the leak
Time held at high airway pressure
∴High frequency ventilation may reduce fistula leak

30. HFV in BPF
Superior to conventional ventilation in controlling PCO2 & PO2 in proximal BPF & normal lung parenchyma
Controversial in peripheral BPF with parenchymal disease (e.g. ARDS)
Initial settings:
Begin with MAP similar to or slightly lower than that of conventional ventilation
Use higher frequency (13-15Hz)
Amplitude to achieve minimal chest movement

31. Potential Complications of HFV
Suboptimal humidification
Inspissation of airway secretions
Necrotizing tracheobronchitis
Gas trapping

32. Treatment of BPF Operative Non-operative
Drainage of infected pleural space, closure of BPF, and obliteration of dead space:
Omental flap
Transsternal transpericardial bronchial closure
Eloesser muscle flap
Thoracoplasty
Conservative
Chemical pleurodesis via chest drain
Bronchoscopic methods
60cm
Patient
Underwater seal
ANZ J Surg Aug;76(8):754-6

33. Bronchoscopy in BPF Diagnostic: Therapeutic:
Direct visualization of proximal fistula
Distal fistula localized by systematically occluding bronchial segments by balloons
Therapeutic:
Distal small fistulas (~1mm) can be sealed by various agents:
Glue, blood patch, coils, gel foams, lead shots
No evidence to support the use of one over another

34. Bronchoscopy in BPF Amplatzer device
Endobronchial valve (Emphasys)
Commonly used for closure of atrial septal defects.
For closure of larger BPF.
Large range of device sizes & can be matched to size of fistula.
Chest 2008; 133(6):
Designed primarily for endoscopic lung volume reduction in emphysema.
One-way valve that prevents entry of air but allows drainage of secretions.
Thorax 2007; 62: 830-3

35. Bronchoscopy in BPF
Endobronchial Watanabe Spigot (EWS) (Novatech, Grasse, France)
A silicone-made bronchial filler for bronchial occlusion
Flexible bronchoscope under LA
J Bronchol 2003; 10: 264-7

36. Bronchial Occlusion With Endobronchial Watanabe Spigot
J Bronchol 2003; 10: 264-7
63 cases in Japan between April 2000 and March 2002
40 intractable pneumothorax
12 pyothorax with bronchial fistula
7 pulmonary fistula, 1 bronchial fistula
1 bronchobiliary, 1 bronchoesophageal fistula, and 1 bronchogastric fistula

37. Bronchial Occlusion With Endobronchial Watanabe Spigot
Technically successful bronchial occlusion
In 58/60 (96.7%)
Average 4 EWS/case used
J Bronchol 2003; 10: 264-7

38. Take Home Messages
BPF is an abnormal communication between bronchial tree & pleural space associated with significant mortality
No established guidelines in the management of BPF
Early recognition, drainage, & management of infection are critical
Recognizes the potential problems with positive pressure ventilation, although conventional ventilation usually suffices
List of available options represent personal experience not subjected to vigorous testing

39. References Radiographics 2006;26:1449-1468
Crit Care 2005; 9(6): 594–600
Chest 1986; 90:
Chest 1990; 97:
Chest 2005; 128(6):
Chest 2008; 133(6):
Thorax 2007; 62: 830-3
J Bronchol 2003; 10: 264-7

40. THANK YOU