Download Bronchopleural fistula

Bronchopleural fistula
Sudhir Rao
Respiratory
What ? How ?
• Communication between the bronchial tree and the pleural space
• Common aeitiology- pulmonary resection
lung necrosis complicatinginfection
chemotherapy
radiotherapy
persistent spontaneous pneumothorax
tuberculosis
lung neoplasm
blunt & penetrating lung injuries
chest tube drains/ thoracocentesis
Risk factors, incidence & mortality
•
•
Peri-operative risk factorsPre- 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)
• IncidenceFollowing 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 causesaspiration pneumonia & subsequent ARDS
tension pneumothorax
How do they present?
• Acutesudden 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 Postoperative cases)
• Subacutewasting, malaise, fever and cough
• Chronic(usually associated with an infectious process)- there is fibrosis
of pleural space and mediastinum, typically preventing mediastinal
shift
Diagnosis
• BronchoscopyDirect 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 channelabsence of capnographic tracing suggesting communication to air,
suggests BPF { disconnect chest tube from UWSD}
• CT scanto 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
Thankyou