Bronchopleural fistula

	WikiDoc Resources for Bronchopleural fistula
Articles
Most recent articles on Bronchopleural fistula Most cited articles on Bronchopleural fistula Review articles on Bronchopleural fistula Articles on Bronchopleural fistula in N Eng J Med, Lancet, BMJ
Media
Powerpoint slides on Bronchopleural fistula Images of Bronchopleural fistula Photos of Bronchopleural fistula Podcasts & MP3s on Bronchopleural fistula Videos on Bronchopleural fistula
Evidence Based Medicine
Cochrane Collaboration on Bronchopleural fistula Bandolier on Bronchopleural fistula TRIP on Bronchopleural fistula
Clinical Trials
Ongoing Trials on Bronchopleural fistula at Clinical Trials.gov Trial results on Bronchopleural fistula Clinical Trials on Bronchopleural fistula at Google
Guidelines / Policies / Govt
US National Guidelines Clearinghouse on Bronchopleural fistula NICE Guidance on Bronchopleural fistula NHS PRODIGY Guidance FDA on Bronchopleural fistula CDC on Bronchopleural fistula
Books
Books on Bronchopleural fistula
News
Bronchopleural fistula in the news Be alerted to news on Bronchopleural fistula News trends on Bronchopleural fistula
Commentary
Blogs on Bronchopleural fistula
Definitions
Definitions of Bronchopleural fistula
Patient Resources / Community
Patient resources on Bronchopleural fistula Discussion groups on Bronchopleural fistula Patient Handouts on Bronchopleural fistula Directions to Hospitals Treating Bronchopleural fistula Risk calculators and risk factors for Bronchopleural fistula
Healthcare Provider Resources
Symptoms of Bronchopleural fistula Causes & Risk Factors for Bronchopleural fistula Diagnostic studies for Bronchopleural fistula Treatment of Bronchopleural fistula
Continuing Medical Education (CME)
CME Programs on Bronchopleural fistula
International
Bronchopleural fistula en Espanol Bronchopleural fistula en Francais
Business
Bronchopleural fistula in the Marketplace Patents on Bronchopleural fistula
Experimental / Informatics
List of terms related to Bronchopleural fistula

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

Empyema necessitans

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	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^[7] Small fistula Advanced malignancies	Bronchoscopic therapies and general measures does not work for large fistulas