Management of bronchopleural fistula in patients on mechanical ventilation
- Andrew M Luks, MD
Andrew M Luks, MD
- Associate Professor - Division of Pulmonary and Critical Care Medicine
- Department of Medicine, University of Washington
When a pneumothorax is detected in a mechanically ventilated patient, air is evacuated from the pleural space by inserting a chest tube and applying external suction. The evacuated air is seen as bubbling through the water seal of the drainage device. Air may continue to leak into the pleural space for minutes to hours, but it will eventually stop in most cases. The bubbling ceases once the lung is fully reinflated and no further air leaks into the pleural space.
A bronchopleural fistula (BPF) exists if the bubbling continues for 24 hours or more. It is indicative of a persistent air leak into the pleural space. Most are small and consist of only a few bubbles escaping through the water seal of the drainage device in synchrony with the inspiratory phase of the ventilator. However, a few leaks are larger and persist through both inspiration and expiration; the volume of such leaks may reach several hundred milliliters per breath.
Although BPF was encountered not infrequently 30 years ago in patients with the acute respiratory distress syndrome (ARDS), in the current era of low tidal volumes and lung-protective ventilation it has become rare as a complication associated with mechanical ventilation. Nonetheless, it remains desirable for clinicians to be familiar with BPF, as it can occur in critically ill patients, and to have an approach to its assessment and management. Assessment and management of a BPF in the setting of mechanical ventilation are reviewed here [1,2]. The pathogenesis, management, and outcomes of BPF following lung surgery are discussed separately [3,4]. (See "Sequelae and complications of pneumonectomy" and "Lung volume reduction surgery in COPD".)
There are many potential causes of bronchopleural fistula (BPF) in mechanically ventilated patients. These include airway disruption or alveolar rupture prior to the initiation of mechanical ventilation (eg, trauma, surgery), laceration of the airway or visceral pleura during mechanical ventilation (eg, central line placement, thoracentesis), and spontaneous alveolar rupture (eg, a complication of the underlying disease or mechanical ventilation). The potential causes of BPF are listed in the table (table 1).
Alveolar rupture due to mechanical ventilation appears to be a consequence of alveolar overdistension due to an excessive inflation volume, more than a consequence of increased airway pressure. This was shown by an animal study in which a high peak inflation volume without increased airway pressure caused alveolar injury, whereas high airway pressure without an increased inflation volume did not cause alveolar injury . The former conditions were created by high tidal volume external negative-pressure ventilation, while the latter conditions were created by strapping the chest and not allowing it to expand despite high inflation pressure. This animal data is supported by the observation that humans frequently have high airway pressures (eg, coughing, bronchospasm without air trapping), but alveolar rupture rarely results. In light of this evidence, the term "volutrauma" is a more accurate description of the pathogenesis of a pneumothorax as a complication of mechanical ventilation than "barotrauma" . The likelihood of volutrauma is increased in the presence of acute lung injury . (See "Diagnosis, management, and prevention of pulmonary barotrauma during invasive mechanical ventilation in adults" and "Inflammatory mechanisms of lung injury during mechanical ventilation".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Kempainen RR, Pierson DJ. Persistent air leaks in patients receiving mechanical ventilation. Semin Respir Crit Care Med 2001; 22:675.
- Luks AM, Pierson, DJ. Barotrauma and bronchopleural fistula. In: Principles and Practice of Mechanical Ventilation, 3rd ed, Tobin MJ (Ed), McGraw-Hill, New York 2012.
- Puskas JD, Mathisen DJ, Grillo HC, et al. Treatment strategies for bronchopleural fistula. J Thorac Cardiovasc Surg 1995; 109:989.
- Slade M. Management of pneumothorax and prolonged air leak. Semin Respir Crit Care Med 2014; 35:706.
- Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure. Am Rev Respir Dis 1988; 137:1159.
- Dreyfuss D, Saumon G. Barotrauma is volutrauma, but which volume is the one responsible? Intensive Care Med 1992; 18:139.
- Dreyfuss D, Soler P, Saumon G. Mechanical ventilation-induced pulmonary edema. Interaction with previous lung alterations. Am J Respir Crit Care Med 1995; 151:1568.
- Doelken P, Sahn SA. Pleural Disease in the Critically Ill Patient. In: Intensive Care Medicine, 6th, Irwin RS, Rippe JM (Eds), Lippincott Williams & Wilkins, Philadelphia 2008. p.625.
- Larson RP, Capps JS, Pierson DJ. A comparison of three devices used for quantitating bronchopleural air leak. Respir Care 1986; 31:1065.
- Bishop MJ, Benson MS, Pierson DJ. Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome. Chest 1987; 91:400.
- Litmanovitch M, Joynt GM, Cooper PJ, Kraus P. Persistent bronchopleural fistula in a patient with adult respiratory distress syndrome. Treatment with pressure-controlled ventilation. Chest 1993; 104:1901.
- Charan NB, Carvalho CG, Hawk P, et al. Independent lung ventilation with a single ventilator using a variable resistance valve. Chest 1995; 107:256.
- Cheatham ML, Promes JT. Independent lung ventilation in the management of traumatic bronchopleural fistula. Am Surg 2006; 72:530.
- Santini M, Vicidomini G, La Monica G, Pastore V. Use of a modified endobronchial tube for mechanical ventilation of patients with bronchopleural fistula. Eur J Cardiothorac Surg 2005; 28:169.
- Galvin I, Krishnamoorthy R, Saad RS. Management of advanced ARDS complicated by bilateral pneumothoraces with high-frequency oscillatory ventilation in an adult. Br J Anaesth 2004; 93:454.
- Ha DV, Johnson D. High frequency oscillatory ventilation in the management of a high output bronchopleural fistula: a case report. Can J Anaesth 2004; 51:78.
- Campbell D, Steinmann M, Porayko L. Nitric oxide and high frequency jet ventilation in a patient with bilateral bronchopleural fistulae and ARDS. Can J Anaesth 2000; 47:53.
- Darwish RS, Gilbert TB, Fahy BG. Management of a bronchopleural fistula using differential lung airway pressure release ventilation. J Cardiothorac Vasc Anesth 2003; 17:744.
- Fuso L, Varone F, Nachira D, et al. Incidence and Management of Post-Lobectomy and Pneumonectomy Bronchopleural Fistula. Lung 2016; 194:299.
- Varoli F, Roviaro G, Grignani F, et al. Endoscopic treatment of bronchopleural fistulas. Ann Thorac Surg 1998; 65:807.
- Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest 2005; 128:3955.
- McCormick BA, Wilson IH, Berrisford RG. Bronchopleural fistula complicating group A beta-haemolytic streptococcal pneumonia. Use of a Fogarty embolectomy catheter for selective bronchial blockade. Intensive Care Med 1999; 25:535.
- Sprung J, Krasna MJ, Yun A, et al. Treatment of a bronchopleural fistula with a Fogarty catheter and oxidized regenerated cellulose (surgicel). Chest 1994; 105:1879.
- Nicholas JM, Dulchavsky SA. Successful use of autologous fibrin gel in traumatic bronchopleural fistula: case report. J Trauma 1992; 32:87.
- Baumann WR, Ulmer JL, Ambrose PG, et al. Closure of a bronchopleural fistula using decalcified human spongiosa and a fibrin sealant. Ann Thorac Surg 1997; 64:230.
- Travaline JM, McKenna RJ Jr, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009; 136:355.
- Abu-Hijleh M, Blundin M. Emergency use of an endobronchial one-way valve in the management of severe air leak and massive subcutaneous emphysema. Lung 2010; 188:253.
- Mahajan AK, Verhoef P, Patel SB, et al. Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients. J Bronchology Interv Pulmonol 2012; 19:137.
- Takahashi M, Takahashi H, Itoh T, et al. Ultraflex expandable stents for the management of air leaks. Ann Thorac Cardiovasc Surg 2006; 12:50.
- Bellato V, Ferraroli GM, De Caria D, et al. Management of postoperative bronchopleural fistula with a tracheobronchial stent in a patient requiring mechanical ventilation. Intensive Care Med 2010; 36:721.
- Martin WR, Siefkin AD, Allen R. Closure of a bronchopleural fistula with bronchoscopic instillation of tetracycline. Chest 1991; 99:1040.
- Wang KP, Schaeffer L, Heitmiller R, Baker R. NdYAG laser closure of a bronchopleural fistula. Monaldi Arch Chest Dis 1993; 48:301.
- Pierson DJ, Horton CA, Bates PW. Persistent bronchopleural air leak during mechanical ventilation. A review of 39 cases. Chest 1986; 90:321.