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Bronchopleural Fistula

• Etiology of Bronchopleural Fistula (BPF):
  • Trauma, empyema/abscess, bullous disease, post lung resection, carcinoma
• Comorbid Disease:
  • Chronic obstructive lung disease, malignancy, coronary artery disease, arrhythmias
• Absolute Indication for Lung Separation:
  • Protection of healthy lung from soiling
  • Ineffective ventilation (with chest tube in place)
  • Tension pneumothorax (without chest tube in place)
  • Systemic air embolus
• Repeat Thoracotomy Considerations:
  • Hemorrhage
  • Sepsis, septic shock
  • Postoperative analgesia
  • Postoperative ICU disposition for positive pressure ventilation (PPV)

Complications of IPPV in BPF

Size of Fistula Estimation

• Indication via mechanism of injury 
• Excessive bubbling in underwater drain
• Respiratory distress & variation in tidal volume (TV) during inspiration and expiration
• Chest X-ray: Lung collapse despite drain insertion 
• CT scan: Visualization of fistula size

Approach

View or edit this diagram in Whimsical.

Goals & Conflicts

• Lung Isolation Prior to PPV:
  • Prevent pathophysiological complications
  • Challenges: full stomach, difficult airway, hemodynamic instability, limited functional reserve
• Rapid Sequence Lung Isolation Techniques:
  • Regional anesthesia
  • Awake fibreoptic intubation: single lumen endotracheal tube (ETT) ± bronchial blocker, double lumen ETT prior to general anesthesia (GA)
  • Asleep intubation with spontaneous ventilation prior to isolation
  • Modified rapid sequence induction (RSI) with no or limited PPV prior to lung isolation
  • Double lumen ETT preferred to bronchial blocker for optimal suctioning, ventilation, and isolation
• Need for Resuscitation & Stabilization Prior to OR:
  • Fluids, vasopressors, antibiotics, chest tube placement
  • Immediate availability of thoracic surgeon for chest tube placement if not in place prior to OR
• Intraoperative Goals:
  • Lung protective ventilation
  • Restrictive fluid strategy
  • Maintenance of normothermia & normal metabolic parameters
• Optimization for Postoperative Extubation:
  • Resuscitation
  • Bronchial suctioning
  • Bronchodilators
  • Extubation to BiPAP

Induction

• Small Fistula:
  • Conventional induction
• Large Fistula:
  • Spontaneous respiration (gas induction or awake intubation)
  • Position patient with “fistula side down”
• Double Lumen Tube (DLT):
  • More secure but requires patient to be asleep during intubation
• Single Lumen Tube (SLT) & Bronchial Blocker (BB):
  • Less secure but allows patient to be awake during intubation
• Alternative Options:
  • Thoracic epidural
  • Extracorporeal membrane oxygenation (ECMO)

Ventilation

• Small Fistula:
  • Managed with single lumen ETT
  • Small tidal volume (TV)
  • Increased respiratory rate (RR)
  • Elimination or minimization of positive end-expiratory pressure (PEEP)
• Large Fistula:
  • May need double lumen ETT
  • Ventilation strategies for the lung with the fistula:
    • Increased RR and small TV
    • Continuous positive airway pressure (CPAP) below critical pressure
    • High-frequency jet ventilation

Links

• Double lumen and Bronchial blocker
• Respiratory physiology and Thoracic anaesthesia
• Open chest and Empyema
• Lung resection
• Bronchiectasis

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References:

1. Camargo, A. A. d., Lanza, F. C., Tupinambá, T., & Corso, S. D. (2013). Reproducibility of step tests in patients with bronchiectasis. Brazilian Journal of Physical Therapy, 17(3), 255-262. https://doi.org/10.1590/s1413-35552012005000089
2. Salik I, Vashisht R, Sharma S, et al. Bronchopleural Fistula. [Updated 2024 Aug 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534765/
3. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/

Summaries:

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Copyright
© 2025 Francois Uys. All Rights Reserved.

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