Bronchopleural fistula
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Transcript of Bronchopleural fistula
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