Dr Chiranjib BhattacharyyaAssociate Professor

Dept. Of AnaesthesiologyIPGMER KOLKATA

BRONCHOPLEURAL FISTULA

INTRODUCTIONCommunication between bronchial

tree and pleural spaceHigh morbidity and mortalityProlonged hospital stayNo standard treatment guidelines or

consensusAetiology : 1.postoperative – 2/3 2.non-operative – 1/3

CLASSIFICATION OF AIR LEAKS Alveolopleural fi stula(APF):pulmonary-

pleural communication distal to segmental bronchus, common after lung resection except pneumonectomy, heal conservatively.

BPF: communication between a mainstem, lobar or segmental bronchus and the pleura lined cavity, usually require surgical intervention

4.5%-20% after pneumonectomy and 0.5% after lobectomy

Predisposing factors: 1.h `Rt.pneumonectomy 2. Uncontrolled pleural/pulmonary infection 3. Preop. radiation,steroid,cirrhosis,diabetes 4. Uncorrected low serum albumin, anaemia 5. Malignancy 6. Contd.mechanical ventilation for more than 24h 7. H influenzae in sputum 8. Fever, high ESR

POSTOPERATIVE BPF

Main bronchus,intermdt bronchus has higher risk compared to lobar bronchus

Long bronchial stump, residual tumour, excessive peribronchial and paratracheal dissection-harmful

Routine coverage of stump with omentum, intercostal muscle flap, pleural flap, pericardial fat esp after right pneumonectomy suggested

POSTOPERATIVE BPF (CONTD.)

NONPOSTOPERATIVE BPF

Infection- pneumonia, lung abscess,TB,empyema

ARDS Persistent spontaneous pneumothorax Thoracic trauma Iatrogenic eg line placement,lung biopsy,pleural

biopsy bronchoscopy Necrotising lung disease associated with

radiation,chemotherapy Spontantaneous rupture of bulla,cyst Erosion of bronchial wall:

malignancy,FB,chr.inflammation

CLINICAL PRESENTATION

o Usually 7-15 days following a lung resection

o Early (1-7days ), intermediate ( 8-30 days ) and late ( more than 30 days )

o As complication of pleuropulmonary infection-any time during the course of the illness

o Early indicators: reappearance of fever,increased cough with purulent/serosanguinous sputum

o Persistent bubbling from the chest drain

CLINICAL PRESENTATION (CONTD)

ACUTE: sudden onset of dyspnoea,cough,expectoration of purulent material,hypotension,subcutn.emphysema,shifting of trachea and mediastinum.

SUBACUTE: insidious onset of fever,malaise,wasting,minimally productive cough

CHRONIC: associated with infectious disease,minimal mediastinal shift due to pleural and mediastinal fibrosis,not life threatening,adequate gas exchange in healthy lung

Systemic features of sepsis

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

DIAGNOSIS CLINICAL Persistent air leak: >24h after

development of pneumothorax Exclude other causes of persistent

air leak: 1.an external air leak 2.extrathoracic location of side holes 3.disconnections

DIAGNOSIS (CONTD.)

Plain x-rays may reveal following features of BPF :

1.steady increase in intrapleural airspace 2.appearance of a new air fluid level (indicates level of the BPF) 4.development of tension pneumothorax 5.drop in air fluid level exceeding 2cm (in absence of chest tube )

DIAGNOSIS CONTD.

Role of CT Scan: demonstrates pneumothorax,pneumomediastinum,underlying lung pathology

Demarcation of actual fistulous communication Role of FOB: can confirm and localise the BPF FOB and selective bronchography Visualisation of continuous return of air

bubbles on bronchial wash Selective instillation of methylene blue into

segmental bronchi: appears in chest drain,sputum

ROLE OF FOB (CONTD.) FOB aided placement of balloon-tipped

catheter in selective airway: inflation of balloon eliminates leak

Combined FOB and Capnography : polyurethane catheter passed through br.scopic channel and introduced into different bronchi

BPF suggested by loss of capnographic tracing: affected bronchus communicates to atmosphere through chest tube

BPF WITH FISTULA OPENING BEING VISIBLE ON FOB

Post pneumonectomy bronchopleural fistula, (A)right hydropneumothorax, (B) FOB showed a possible fistulousopening at the right bronchial stump, (C) methyleneBlue injected at the suspected site, (D) appearance of dyein the pleural drainage system confirmed the diagnosis.

DIAGNOSIS (CONTD.)

Changes in gas concentration in pneumonectomy cavity after inhalation of different conc. of O2,N2O

Ventilation scintigraphy using radioactive gases, eg.

133Xe that accumulate in pleural space within and remain trapped in the pleural space in washout study

High incidence of false negative results Inhalation of radio-labelled aerosols with planar

and SPECT imaging: requires patient cooperation, false positives occur, direct estimation of size of BPF not possible

AIR LEAKS : FUNCTIONAL CLASSIFICATION 1.The largest(C): continued bubbling through

chest tube,least common,pts on mech.ventilation

2.The 2nd largest(I): air leak only during inspiration,pts on mech. ventilation with large APF or small BPF

3.The 3rd largest(E): air leak only during expiration,after lung surgery due to APF

4.The smallest(FE): air leak only during forced expiration eg. coughing,common after lung resection

Small leaks heal with underwater drains but larger leaks may require suction

Persistent pneumothorax: air escaping through

the BPF delays healing of the tract Inadequate ventilation: significant loss of TV Pendelluft: seen in early BPF when

mediastinum is mobile V/Q mismatch Infection of pleural space Most common cause of death in BPF: aspiration

pneumonia and ARDS,tension pneumothorax

CONSEQUENCES OF BPF

PROBLEMS WITH LARGE BPF IN ICUDifficult to wean from ventilatorInability to apply PEEPFailure to expand the remaining lungHypoxia, hypercarbiaMay need dual ventilationMay need HFVHigh mortality: occurrence of BPF during

mechanical ventilation identifies pts. with high mortality

TREATMENT OF BPF

Treatment options include: surgical procedures,medical therapy,bronchoscopic- guided placement of glue,coils,sealants etc

Initial treatment: control of life-threatening conditions

Tension pneumothorax: urgent insertion of chestdrain

Pulmonary flooding: immediate airway control,postural drain with affected side down

Major bronchial stump dehiscence: immediate resuture with reinforcement

TREATMENT (CONTD)

Aggressive management of underlying comorbidities

Haemodynamically unstable pt. with varying degrees of resp. failure

Superadded sepsisPoor nutrition, hypoalbunaemia, anaemiaUnresolved empyema, underlying

tubercular/fungal infectionPoor candidates for a second surgical procedureNeed care in ICU setup

TREATMENT ( CONTD.)

o Drainage of pleural space with proper antimicrobial coverage

o Enteral or parenteral nutritiono Correction low albumin and haematocrito Mechanical ventilatory support if required

ROLE OF CHEST TUBE IN BPF

Indicated in all pts. with high flow BPF and drainage of empyema

Add positive intrapleural pressure during expiration to reduce air leak and maintain PEEP

Intermittent occlusion during inspiratory phase to decrease BPF flow

Useful in patients with ARDS Can function as foreign body and delay healing Predispose to infection at insertion site and

pleural space

CHEST TUBE (CONTD.) Loss of tidal volume Abnormal gas exchange Inappropiate ventilator cycling Tube should of sufficient diameter to allow

free drainage of air leak Flow varies with 5th power of tube radius in

clinical situations due to turbulent flow of moist air( Fanning equation )

Pleurodesis: sclerosing agent eg bleomycin can be passed through tube

MECHANICAL VENTILATION IN BPF

Air leaks may range from 1-16L/min Loss of effective TV and PEEP, incomplete

lung expansion,CO2 retention, auto-triggering of ventilator, severe hyperventilation

Excess use of sedatives, muscle relaxants Goal: 1. keep airway pressure at or below

critical opening pressure of fistula 2.adequate pleural space decompression to allow lung re-expansion

MECHANICAL VENTILATION (CONTD.)

Increased chest tube suction increases flow through BPF, so use least possible pressure or none at all

Limiting the amount of PEEP during ventilation Limiting effective tidal volume Shortening the inspiratory time Reducing the respiratory rate Reducing the proportion of minute volume

supplied by ventilator Differential lung ventilation using a DLT Independent lung ventilation using 2

ventilators

HIGH FREQUENCY VENTILATION IN BPF

Results are conflicting More useful in pts. with normal lung

parenchyma and proximal BPF Can be useful in pts. with massive air leak Have been successfully used in pts. with

bilateral BPF Less effective in pts. with bilaterally

diseased noncompliant lungs Major handicap: doesn’t allow isolation of

lungs

THERAPEUTIC BRONCHOSCOPY IN BPF

oAllows inspection of the stumpoConfirms location and size of the BPFoBronchoscopy aided application of sealant

substance can be triedo Intrabronchial stents, valves,embolisation coils

etc have been usedoSuitable for small fistulas ( <5mm diam )oProximally located fistula-mainstem, lobar or

segmental bronchi are more suitableoUseful alternative in patients not proper

candidates for surgery

SURGICAL PROCEDURES IN BPF• Decortication of lung

• Revision of bronchial stump

• Closure of fistula with muscle flap from intercostal space

• Thoracoplasty combined with pedicle muscle flap to cover bronchial stump

• Resection of diseased chronically infected lung segments

Experienced thoracic anaesthesiologist Problems in anaesthesia for BPF pts.: 1.Isolation of the healthy lung reqd. 2.Prevention of tension pneumothorax during

PPV 3.Inadequate ventilation due to loss of gas

through fistula 4.Significant intraoperative blood loss 5.Patient preparation may be suboptimal 6.Early extubation and avoidance of

postoperative PPV desirable

ANAESTHETIC MANAGEMENT OF BPF

Assessment of possible loss of TV through the fistula:

bubble flow through chest drain continous or intermittent

Quantification of size of BPF: inhaled TV– exhaled TV Nonintubated pt.: tight fitting mask and fast

responding spirometer Intubated pt.: direct attachment of spirometer to

ETT Larger the leak,greater need to isolate BPF by lung

isolation Devices: DLT,SLT,independent bronchial blocker

ANAESTHESIA FOR BPF (CONTD.)

ANAESTHESIA FOR BPF (CONTD.)DLT advantages: 1.most secure method of isolation 2.allows easy bilateral suction and ventilation 3.differential lung ventilation possibleDLT disadvantage: most difficult to place in awake

patients under topical anaesthesia of airwaySLT disadvantage: 1.doesnt allow easy suction or ventilation of

affected lung 2. not designed for endobronchial use 3.if placed in R mainstem bronchus will obstruct

orifice of RUL

ANAESTHESIA FOR BPF (CONTD.)Bronchial blocker advantages: 1.can be deflated to suction or ventilate BPF lung 2.allows lobar isolationDisadvantage: least secure method of lung isolationAbility to deliver PPV must be assessedWorking chest drain prior to inductionSLT safe to use: if fistula small, chronic,uninfectedDLT best choice for PPV: if significant airleak presentUsual MV can be delivered to healthy lung,no loss

through fistula and no risk of contamination on turning the pt.

o Emergency situation: SLT can be used,provides

protection and ventilation to healthy lungo Non pneumonectomy pt.: BB can be placed through

ETT into mainstem bronchus of affected side,less stable,less protection to the healthy lung

o Post pneumonectomy pt.: BB is not an option due to short length of bronchial stump available

o Anaesthetic management options include:o 1.awake fibreoptic intubation with SLT,DLT or BB.o Induction of GA after lung isolation is achieved

ANAESTHESIA FOR BPF (CONTD.)

Safest method but technically most difficult Requires excellent pt. cooperation and thorough airway

topical anaesthesia 2.Induction of GA maintaining spont.ventilation using

deep inhalational anaesthesia PPV avoided lungs are isolated Breath holding and laryngospasm may nessecitate

unplanned use of PPV Vigorous coughing in either technique may provoke

spillover into healthy lungs and reopen a fistula Significant hypotension can occur in elderly,debilitated

pts.

ANAESTHESIA FOR BPF (CONTD.)

ANAESTHESIA FOR BPF

3.If airway is thought to be easy, rapid sequence induction can be done avoiding PPV until lung isolation.

Position for induction: head up position maintained as long as possible with 30deg lateral tilt keeping diseased lung down

Post pneumonectomy pts.; DLT or SLT placed under direct vision with help of FOB for accurate placement and avoiding injury to bronchial stump

Suction of chest tube to be avoided during induction: to reduce loss of TV with PPV

ANAESTHESIA FOR BPF (CONTD.)

Chest open, SLT used, excessive air leak: lungs packed off and manual compression of fistula by surgeon

Rigid bronchoscope can be introduced under topical anaesthesia of airways or inhalation anaesthesia: observation of fistula, suction,positioning of endobronchial tube or BB, jet ventilate the healthy lung

Extubation: as soon as feasible as neg. pr. ventilation is best

Bronchial tree examined with FOB before extubation

If postop ventilation is necessary DLT is not changed

Thoracic epidural analgesia for post operative analgesia

TEA has been used as sole anaesthetic technique in BPF closure in elderly debilitated pts.

ANAESTHESIA FOR BPF (CONTD.)

REFERENCES Sarkar P et al Diagnosis and Management

Bronchopleural Fistula Indian J Chest Allied Sci 2010;52:97-104

Manuel L et al Bronchopleural Fistulas An Overview of the Problem With Special Focus on Endoscopic Mnagement CHEST 2005;128:3955-3965

Sanjay O P et al Management of Bronchopleural Fistula. Core Topics in Thoracic Anaesthesia Chapter 27,OUP 2009

Principles and Practice of Anaesthesia for Thoracic Surgery.ed P Slinger 2011 Pg 467-71