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
- Chemotherapy and radiation
- Diabetes mellitus
- Heavy smoking and COpD
- Low nutritional status
- Residual tumor at bronchial margin
- Extensive lymph node dissection
- Older age
- Long term postoperative mechanical ventilation
- Tuberculous of fungal infection
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 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.
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 -
Bronchoscopy: Bronchopleural Fistula -
Bronchoscopy: Bronchopleural Fistula -
Bronchoscopy: Bronchopleural Fistula
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Pre fistula radiograph -
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