Bronchopleural fistula

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pEditor-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 is a sinus tract between the bronchus and the pleural space that may result from many reasons but most commonly following pneumectomy, or sometimes due to tumors at bronchial margin. It can also occur in response to chemotherapy, radiotherapy COpD, lymph node dissection, long term mechanical ventilation and infections. On imaging, the diagnosis is suspected indirectly on radiograph. Increased gas in the pneumonectomy operative bed, or new gas within a loculated effusion are highly suggestive of the diagnosis. Although radiograph can help in diagnosing it but CT gives a better picture.

It can present with acute or subacute symptoms. It presents with symptoms such as sudden onset dyspnea, chest pain, hemodynamic instability in acute setting. The subacute presentation shows up with emphysema, fever, malaise. Depending on how the patient presents, general suppprtive care and surgical repair are the treatment options.

Pathophysiology

Bronchopleural fistula can occur due to necrotising pneumonia/empyema (anaerobic, pyogenic, tuberculous, and fungal), lung neoplasms, blunt and penetrating lung injuries. It can also occur as a complication of procedures, such as  lung biopsy, chest tube drainage, thoracocentesis or may complicate radiation therapy. Most commonly it occurs as a complication of lung surgery. When the bronchial stump fails to heal, a sinus tract is formed between bronchus and pleura, which causes continuous air leak into the pleura. This failure to heal can be from improper initial closure, inadequate blood supply, infection or residual malignant tumour at the bronchial stump.

Epidemiology and Demographics

The incidence of  varies from 4.5% to 20% after pneumonectomy and 0.5% after lobectomy. Certain patient characteristics increase this incidence. preoperative radiation to the chest, destroyed or infected lung from inflammatory disease, immunocompromised or immunesuppressed host, diabetes, hypoalbuminemia, cirrhosis, steroid administration, pneumonectomy, right-sided pneumonectomy, a long bronchial stump, residual cancer at the bronchial margin, devascularization of the bronchial stump, prolonged ventilation, or reintubation after resection and surgical inexperience are the factors which may make patient more vulnerable to having BPF. The increased risk of BPF associated with right pneumonectomy is due to the need of more extensive resection required in right pneumonectomy. Mortality rates varies between 18 percent to 67 percent in BPF. The most common cause of death is aspiration pneumonia and subsequent acute respiratory distress syndrome or development of tension pneumothorax.

Etiology

Bronchopleural fistula mostly develops after lung resection surgery. Some other causes of bronchopleural fistula are

• Right sided surgery
• Chemotherapy and radiation
• Malignancies such as
  • Lung cancer
  • Thyroid cancer
  • Esophageal cancer
  • Lymphomas
• Diabetes mellitus
• Gastrointestinal causes such as
  • Gastroesophageal reflux disease with Barrett esophagus
  • Boerhaave syndrome
  • Broncholithiasis
• Heavy smoking and COpD
• Low nutritional status
• Residual tumor at bronchial margin
• Extensive lymph node dissection
• Traumatic and iatrogenic etiologies
  • Thoracic trauma with tracheobronchial tree disruption
  • Post-surgical (eg. lobectomy or lung biopsy) - by far the most common cause.
  • Bougie intubation
  • Necrotizing lung disease
  • ARDS
  • Ventilator-induced barotrauma
  • Excessive manual ventilation
  • Central line placement
  • Complication of bronchoscopy
• Older age
• Long term postoperative mechanical ventilation specially following criteria predisposes patient to BPF
  • High suction of the ICC
  • High tidal volumes
  • High inspiratory pressures
• Tuberculous of fungal infection. Other infections such as
  • Haemophilus influenzae
  • Streptococcus viridans
  • Staphylococcus aureus
  • Pseudomona aeruginosa
  • Klebsiella pneumoniae
  • Pneumococcus
  • Nonhemolytic streptococcus
  • Aspergillus
  • Histoplasma capsulatum

Natural History, Classificatio And Prognosis

Patients with BPF can present with symptoms that range from acute symptoms to subacute symptoms. Most patients present in the first two weeks following lung resection. Bronchopleural fistula occurring postoperatively after lung resection almost always occur within three months of surgery while those developing as a complication of pleuropulmonary infections may develop at any point of time during the course of illness. BPF should be suspected in the postoperative lung resection patient who presents with sudden onset of dyspnea, chest pain, hemodynamic instability, and subcutaneous emphysema. Symptoms may be less abrupt in those who have chest tube placed. In such patients, a large persistent or new air leak through the chest tube drainage system may be the only sign.i

Patients who present in the late postoperative period (more than 14 days) usually present with symptom of empyema. These include fever, malaise, muscle wasting, cough with purulent sputum, reduced air entry and dullness to percussion on the affected side.

Changes in the air-fluid pattern on chest radiograph after surgery are critical as warning signs of BPF. ru Large fistula causing aspiration to the contralateral lung if a tension pneumothorax can develops acute respiratory distresrax. Varoli classified  fistulas according  to the time of onset after the operation:

• Early [1 to 7 days]
• Intermediate [8 to 30 days]
• Late  fistulas [more than 30 days]

Mortality rates vary between 18% to 67%. In BPF the most common cause of death is aspiration pneumonia and subsequent acute respiratory distress syndrome or development of tension pneumothorax.[23]  Later development of BPF and larger leaks are among bad prognostic factors. Uie ofsing omental and thoracic flduring surgical repair have shown decreased mortality.

Clinical features

Symptoms can vary from acute, with in first two weeks postoperative period, to subacute ie. >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

Following complications can arise due to formation of Bronchopleural fistula.

• failure of lung re-expansion
• loss of a significant amount of each delivered TV
• loss of PEEP
• inappropriate cycling of ventilator
• inability to maintain alveolar ventilation
• Empyema necessitans
• death

Examination

Examination plays a vital role in diagnosing bronchopleural fistula. A careful early examination can lead to early diagnosis and hence good prognosis. Examination should involve the following steps

• Examine the patient (an ABC based primary survey, ensuring that the patient is not about to die of pneumothorax or mediastinal shift and is vitally stable)
• Exclude drain dislodgement (examine the drain)
• Quantify the leak by asking the patient to follow below given instructions.
  • Ask the patient to cough
  • Ask the patient to speak
  • Observe the quantity of bubbles.
  • If bubbling is constantly happening while the patient is speaking, the leak is significant.
  • If the bubbling is only present with cough and diminishes with ssutained coughing, the leak is probably small.

On auscultation, percussion and checking position of trachea, following findings might be present

• Reduced air entry on affected side
• Dullness to percussion of affected side
• Tracheal deviation (if tension pneumothorax

Diagnosis

The diagnosis must be suspected in a postoperative lung resection patient when there is a

• persistent air-leak (immediate post-operative period)
• a new or increasing air-fluid level
• disappearance of pleural fluid on chest radiograph, if patient has no chest tube in place.

With a delayed BPF, a new air fluid level appears in a previously opacified haemithorax.

Imaging

Radiological features and CT scan that suggest the presence or the development of a BPF. Following features can be seen on a radiograph but are better appreciated on CT which hints towards formation of BPF

• Increase in intrapleural air space
• Appearance of a new air fluid level
• Changes in an already present air fluid level
• Drop in air fluid level exceeding 2 cm
• Cavity mass in case of malignancy
• pneumothorax
• pneumomediastinum
• Subcutaneous emphysema
• Failure of postpneumonectomy space to fill with fluid
• Air bubbles around surgical side
• Fistula

Bronchoscopy

The presence of BPF is suggested by the return of continuous bubbles during bronchial washing. A bronchoscope with inflation of a balloon-tipped catheter into selected airways can aid in localization, as balloon occlusion decreases or eliminates an air. Small metallic probes introduced through the working channel of the bronchoscope, and changes in gas concentration in the pneumonectomy cavity after inhaling different concentrations of oxygen and N2O are also useful. It can help in determining

• proper evaluation of stump
• Surgical site
• Fistula size and site
• Mucosal defect
• Localization of fistula by instilling dye
• Rule out other etiologies

While a large BPF is more likely to be seen on bronchoscopy, sequential balloon occlusion of the bronchi is sometimes used, particularly for the localization of a smaller or segmental BPF.

CT Bronchography

Computed tomography bronchography (CTB) has been used to diagnose difficult BPF. 20 to 30 mL of a water-based nonionic low osmolar iodinated contrast medium iois injected hexol at the suspected fistula site following bronchoscopy either through a catheter or directly through the working channel of the bronchoscope . The fistula was easily visualized using standard axial and sagittal se on CT.

Capnography

Capnography can be used to identify the bronchial segment related to BPF. End-tidal carbon dioxide is measured by connecting a capnograph to a polyethylene catheter and has a reported a sensitivity of 83% and a specificity of 100% in the diagnosis of BPF.

Pulsography

Endoscopic monitoring of pulse blood flow in the bronchial stump after pneumonectomy is a reliable method of prediction of the BPF with the probability of 77.2% It is one of the latest modality in diagnosing BPF.

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 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. Thihe advantages and disadvantages of some of the above mentioned measures are discussed bel.a.

rategyt	vantagesd	Disadvantages
h	Easy and readily available Usually well tolerated Does not interfere with weaning of ventilation	Risk of damaging more lung Risk of creating larger leak potentially perpetuates the fistula by negative essure suction Invasive
Low tidal volume Low PEEP Low inspiratory rate Short inspiratory time Tolerate high PCO2 Wean rapidly Extubate early	easy and readily available Usually well tolerated Early extubation is the ideal step to aim for, as spontaneous negative pressure breathing is better for BPF healing than positive pressure ventilation	The BPF itself may frustrate weaning off ventilation Mandatory mode may prolong ventilation time Permissive hypercapnea may lead to respiratory acidosis, which is not ideal for the patient with traumatic brain injury
Independent Lung Ventilation Dual-lumen tube Bronch blocker	Isolation of one lung permits the selective low-volume low-pressure ventilation of the affected lung, and more rapid higher volume ventilation of the unaffected lung. PCO2 levels may be easier to control in this manner	Technically difficult: DLT insertion is one thing; running two ventilators is another. There may be leak of gas and pressure from one lung to another if the seal is imperfect Sedation requirements will  be higher, to tolerate the larger tube and the very unnatural respiratory pattern Local pressure effects of the DLT are also more problematic

Surgical Repair

Surgical repair is usually done in patients if symptoms of bronchopleural effusion arise after lung resection.

patient	procedure	Indication	Contraindication
Acute symptoms	Stump debridement and closure VATS Thoracotomy	Fit for surgery Healthy bronchial stump Expected exyubation	Wait until extubation in patients with Hemodynamic instability Hypoxia
Subacute symptoms	Time to bridge period before surgery by Bronchoscopic Therapies General measures	Empyema poor nutrition status poor physical strength Small fistula Advanced malignancies	Bronchoscopic therapies and general measures does not work for large fistulas

Bronchoscopic therapies are performed depending on size of the fistula. Advantages and disadvantages of some of the invasive strategies have been given below.

Strategy	Advantages	Disadvantage
Surgical Repair	Success rates are between 80 and 95%	It may be impossible to find the leak intraoperatively It may be unfeasible to remove so much lung It may be impossible if there are multiple leaks The patient must tolerate one-lung ventilation This approach requires thoracotomy
Bronchial Stenting	The affected bronchus can be stented over bronchoscopically, thereby blocking the leak. This is a minimally invasive alternative to surgical patch repair	Site of leak should be known The leak must be in an accessible bronchus. This may not work if there are multiple leaks The procedure requires technical expertise The patient must be fit to tolerate the bronchoscopy
Bronchial Occlusion	Similarly to surgery, the affected bronchus is blocked with either a one-way valve or a plug. Other options includes blood clot, cyanoacrylate glue, fibrin, lead shot,  gel foam, calf bone, and various others.	Site of leak should be known The leak must be in an accessible bronchus A major part of the lung may be sacrificed The atelectatic lung may develop infection
Application Of PEEP to ICC	The equal intra and extrathoracic PEEP decreases the leak volume Maintained intra-thoracic PEEP permits higher PEEP levels to be used	Drainage is compromised There is a major risk of rapid tension pneumothorax
OVF	May reduce peak pressures Certainly reduces tidal volume (to ~50ml) Theoretically reduces flow across the BPD, allowing it to heal	This is a very unnatural form of ventilation, and may be poorly tolerated Large amounts of sedation or paralysis will be required
ECMO	This may be the only option for severely hypoxic patients With ECMO, one can limit or totally abolish gas flow through the BPF	All the risks of ECMO apply, as it is a maximally invasive therapy It is not widely available. There is little experience with this in BPF.

Refractory Cases

Occlusive materials can be methyl 2 cyanoacrylate, N butyl cyanoacrylate, albumin glutaraldehyde tissue adhesive, polyvinyl alcohol sponge or fibrin glue. 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 can be used to repair the defect as well. Endobronchial occlusion is also an option on table.

For refractory patients, following interventions could be done.

• Repeat surgery
• Alternate bronchoscopic mathod
• Open window thoracostomy

Follow Up

Monitor

• Clinical symptoms of recurrence
• Chest tube air output
• Radiograph and CT

Bronchoscopy is done if symptoms reappear.

shown below are courtesy of Sedat Altin MD, Levent Dalar MD and Cafer Zorkun MD from Yedikule Education and Research Hospital, Istanbul - Turkey.

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  Bronchoscopy: Bronchopleural Fistula

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  Bronchoscopy: Bronchopleural Fistula

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  Bronchoscopy: Bronchopleural Fistula

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  Bronchoscopy: Bronchopleural Fistula

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  Pre fistula radiograph

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