Management of Bronchopleural Fistula

氣管肋膜廔管

Dr Grace SM Lam

ICU Friday Lecture

16th January, 2009

Bronchopleural Fistula

Communication between the bronchial tree & pleural space

Mortality varies between 18-67% Aetiology

Postoperative 2/3 Non-postoperative 1/3

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

Day 1

Day 2

Day 14Day 30

Post-pneumonectomy CXRs

Radiographics 2006;26:1449-1468

Acute Post-pneumonectomy BPF

Reappearance of air OR a drop in air-fluid level >1.5cm

Mediastinal shift

Subcutaneous or mediastinal emphysema

Contralateral lung consolidation from transbronchial spill

Tension pneumothorax & Pulmonary flooding

Day 22

Radiographics 2006;26:1449-1468

Non-postoperative BPF

Causes: Necrotizing pneumonia, TB, lung abscess &

empyema ARDS Persistent spontaneous pneumothorax Thoracic trauma Iatrogenic (line placement, pleural biopsy, FOB) Irradiation & chemotherapy

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

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

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

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

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

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

Chest 1986; 90: 321-323

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

Chest 1986; 90: 321-323

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)

Chest 1986; 90: 321-323

Mode of MV Assist-control ventilation 33 Intermittent mandatory ventilation 6

Only 2 patients had persistent acidemia PH<7.30 despite adjustment of ventilatory settingsBPF can usually be managed by conventional

ventilation. The need for special ventilation techniques is

uncommon.

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

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: 1426-1430

Independent Lung Ventilation

Crit Care. 2005; 9(6): 594–600

Methods of Lung Separation

Endobronchial Blockers Double Lumen ETT

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)

Methods of Lung Separation

Double Lumen ETT For independent lung ventilation

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

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

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

High Frequency Ventilation

High Frequency Ventilation

Conventional Ventilation Gas transport occurs by

bulk flow /convection & molecular diffusion

VA = f (VT – VDS)

High Frequency Ventilation Delivery of small tidal

volumes (VT V≦ DS) at supra-physiologic frequencies

Governs lung volume &

oxygenationFrequency

Tidal volume & CO2 elimination

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

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

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

Potential Complications of HFV

Suboptimal humidification Inspissation of airway secretions Necrotizing tracheobronchitis

Gas trapping

Treatment of BPF

Operative Drainage of infected

pleural space, closure of BPF, and obliteration of dead space:

Omental flap Transsternal

transpericardial bronchial closure

Eloesser muscle flap Thoracoplasty

Non-operative Conservative Chemical pleurodesis via

chest drain

Bronchoscopic methods

Underwater sealPatient

60cm

ANZ J Surg. 2006 Aug;76(8):754-6

Bronchoscopy in BPF

Diagnostic: 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

Bronchoscopy in BPF

Amplatzer device

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): 1481-4

Endobronchial valve (Emphasys)

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

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

Bronchial Occlusion With Endobronchial Watanabe

SpigotJ 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

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

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

References Radiographics 2006;26:1449-1468 Crit Care 2005; 9(6): 594–600 Chest 1986; 90: 321-323 Chest 1990; 97: 1426-1430 Crit Care 2005; 9(6): 594–600 Chest 2005; 128(6): 3955-65 Chest 2008; 133(6): 1481-4 Thorax 2007; 62: 830-3 J Bronchol 2003; 10: 264-7

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