Bronchopleural fistula: Difference between revisions
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== Etiology == | == Etiology == | ||
Bronchopleural fistula mostly develops after lung resection surgery. Some other causes of bronchopleural fistula are | Bronchopleural fistula mostly develops after lung resection surgery. Some other causes of bronchopleural fistula are | ||
* Right sided surgery | * Right sided surgery<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/29516277|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | ||
* Chemotherapy and radiation | * Chemotherapy and radiation | ||
* Diabetes mellitus | * Diabetes mellitus<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/27063612|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | ||
* Heavy smoking and COpD | * Heavy smoking and COpD<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/27499951|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | ||
* Low nutritional status | * Low nutritional status | ||
* Residual tumor at bronchial margin | * Residual tumor at bronchial margin | ||
| Line 18: | Line 18: | ||
* Older age | * Older age | ||
* Long term postoperative mechanical ventilation | * Long term postoperative mechanical ventilation | ||
* Tuberculous of fungal infection | * Tuberculous<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/29516277|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> of fungal infection<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/25019431|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | ||
== Clinical features == | == Clinical features == | ||
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* Gram Stains | * Gram Stains | ||
* Culture | * Culture | ||
Asses the patient for empyema and treat him for it. | Asses the patient for empyema<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/30054070|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> and treat him for it. | ||
* Broad spectrum intravenous antibiotics until gram stains, culture and sensitivity is available | * Broad spectrum intravenous antibiotics until gram stains, culture and sensitivity is available | ||
* Intrapleural fibrinolytic for patients with infected multi loculated effusions | * Intrapleural fibrinolytic for patients with infected multi loculated effusions | ||
| Line 124: | Line 124: | ||
* Empyema | * Empyema | ||
* poor nutrition status | * poor nutrition status | ||
* poor physical strength | * poor physical strength<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/29348280|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | ||
* Small fistula | * Small fistula | ||
* Advanced malignancies | * Advanced malignancies | ||
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Bronchoscopic therapies are performed depending on size of the fistula. | Bronchoscopic therapies are performed depending on size of the fistula. | ||
[[File:Bronchoscopic intervention for fistula.png|thumb | [[File:Bronchoscopic intervention for fistula.png|thumb|Occlusive materials can be methyl 2 cyanoacrylate, N butyl cyanoacrylate, albumin glutaraldehyde tissue adhesive, polyvinyl alcohol sponge or fibrin glue<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/29109057|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref>. In scelrosants, endobronchial injection of ethanol, polydocanol and tetracycline is given. For small bronchopleural fistula, argon plasma coagulation and neodymium doped yttrium aluminuin garnet laser have been used. Omentum<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/29587951|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> can be used to repair the defect as well. Endobronchial occlusion<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/29443771|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> is also an option on table.]] | ||
For refractory patients, following interventions could be done. | |||
* Repeat surgery | |||
* Alternate bronchoscopic mathod | |||
* Open window thoracostomy<ref>{{Cite web|url=https://www.ncbi.nlm.nih.gov/pubmed/23525638 | |||
https://www.ncbi.nlm.nih.gov/pubmed/26743783 | |||
https://www.ncbi.nlm.nih.gov/pubmed/27220922 | |||
https://www.ncbi.nlm.nih.gov/pubmed/29109057|title=|last=|first=|date=|website=|archive-url=|archive-date=|dead-url=|access-date=}}</ref> | |||
=== shown below are courtesy of Sedat Altin MD, Levent Dalar MD and Cafer Zorkun MD from Yedikule Education and Research Hospital, Istanbul - Turkey. === | === shown below are courtesy of Sedat Altin MD, Levent Dalar MD and Cafer Zorkun MD from Yedikule Education and Research Hospital, Istanbul - Turkey. === | ||
Revision as of 19:09, 1 December 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Overview
A bronchopleural fistula (BPF) is a fistula between the pleural space and the bronchial tree. It sometimes develops following pneumectomy.
Etiology
Bronchopleural fistula mostly develops after lung resection surgery. Some other causes of bronchopleural fistula are
- Right sided surgery[1]
- Chemotherapy and radiation
- Diabetes mellitus[2]
- Heavy smoking and COpD[3]
- Low nutritional status
- Residual tumor at bronchial margin
- Extensive lymph node dissection
- Older age
- Long term postoperative mechanical ventilation
- Tuberculous[4] of fungal infection[5]
Clinical features
Symptoms can vary from acute (with in first two weeks postoperative period to subacute (>14 days
Acute Symptoms
- Sudden onset dyspnea
- Chest pain
- Hemodynamic instability
- Subcutaneous emphysema
- Less severe symptoms in case of chest tube (large persistent or new air leak through chest tube drainage might be the only sign
Subacute Symptoms
- Empyema
- Fever
- Malaise
- Muscle wasting
- Cough with purulent sputum
Complication
Examination
- Reduced air entry on affected side
- Dullness to percussion of affected side
- Tracheal deviation (if tension pneumothorax
Diagnosis
Imaging
Following features can be seen on a radiograph but are better appreciated on CT
- pneumothorax
- pneumomediastinum
- Subcutaneous emphysema
- Failure of postpneumonectomy space to fill with fluid
- Air bubbles around surgical side
- Fistula
Bronchoscopy
It can help in determining
- Surgical site
- Fistula size and site
- Mucosal defect
- Localization of fistula by instilling dye
- Rule out other etiologies
Differential Diagnosis
Reasons for tension pneumothorax in postoperative period can be
- Blocked or displaced chest tube
- Tension Chylothorax
- Hemothorax
- Signs of empyema can be due to infection as well.
Management
General Supportive Care
These measures are usually practiced when bronchopleural fistula has subacute presentation. Drainage of air from pleural space by chest tube thoracostomy. If fluid is collected, it should be sent for following labs
- Cell count
- pH
- Total protein
- LDH
- Glucose
- Cytology
- Triglycerides
- Gram Stains
- Culture
Asses the patient for empyema[6] and treat him for it.
- Broad spectrum intravenous antibiotics until gram stains, culture and sensitivity is available
- Intrapleural fibrinolytic for patients with infected multi loculated effusions
- postural drainage
Maximize nutrition
Treat other co morbidities
For mechanically ventilated patient, lower the level of positive pressure and selectively intubate healthy lung.
Surgical Repair
Surgical repair is usually done in patients if symptoms of bronchopleural effusion arise after lung resection.
| patient | procedure | Indication | Contraindication |
|---|---|---|---|
| Acute symptoms |
|
|
Wait until extubation in patients with
|
| Subacute symptoms | Time to bridge period before surgery by
|
|
Bronchoscopic therapies and general measures does not work for large fistulas |
Bronchoscopic therapies are performed depending on size of the fistula.
For refractory patients, following interventions could be done.
- Repeat surgery
- Alternate bronchoscopic mathod
- Open window thoracostomy[11]
shown below are courtesy of Sedat Altin MD, Levent Dalar MD and Cafer Zorkun MD from Yedikule Education and Research Hospital, Istanbul - Turkey.
-
Bronchoscopy: Bronchopleural Fistula -
Bronchoscopy: Bronchopleural Fistula -
Bronchoscopy: Bronchopleural Fistula -
Bronchoscopy: Bronchopleural Fistula
-
Pre fistula radiograph -
-
-
-
References
- ↑ https://www.ncbi.nlm.nih.gov/pubmed/29516277. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/27063612. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/27499951. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/29516277. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/25019431. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/30054070. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/29348280. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/29109057. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/29587951. Missing or empty
|title=(help) - ↑ https://www.ncbi.nlm.nih.gov/pubmed/29443771. Missing or empty
|title=(help) - ↑ [https://www.ncbi.nlm.nih.gov/pubmed/23525638
https://www.ncbi.nlm.nih.gov/pubmed/26743783
https://www.ncbi.nlm.nih.gov/pubmed/27220922
https://www.ncbi.nlm.nih.gov/pubmed/29109057 https://www.ncbi.nlm.nih.gov/pubmed/23525638 https://www.ncbi.nlm.nih.gov/pubmed/26743783 https://www.ncbi.nlm.nih.gov/pubmed/27220922 https://www.ncbi.nlm.nih.gov/pubmed/29109057] Check
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