Medical Management and Therapy of Bronchopleural Fistulas in the Mechanically Ventilated Patient: MANAGEMENT

8 May

The pulmonologist and intensivist will frequently be called on to advise on the management and therapy of both nonsurgical and surgically related BPFs. Given the incidence of barotrauma and BPFs in the mechan­ically ventilated patient, knowledge of the care of patients with BPFs is requisite for the critical care specialist. Management and definitive therapy of BPFs have frequently involved invasive surgical approaches requiring general anesthesia. Thoracoplasty, surgical approaches with mobilization of the pectoralis or intercostal muscles, bronchial stump stapling, and decortication have been used to seal the site of bronchial leak. Such techniques are still applica­ble and used today. However, a trend toward nonsur­gical management of both acute and chronic BPFs has been evolving that uses the skills of pulmonary and critical care practitioners but may require a refinement of those skills. This trend has included greater sophis­tication and knowledge, not only of stabilization and supportive measures, including chest tube manage­ment, drainage systems, and ventilator support, but also of definitive nonoperative therapy. Such nonopera- tive therapy provides an alternative to the surgical approaches in those patients with BPFs who are poor operative candidates. It is important to note that the techniques described below have been attempted in a limited number of patients and in specific clinical situations. Each patient with a BPF is unique and requires individual management based on his clinical setting.

General Management Goals

Attention to basics of medical care in patients with BPFs should not be neglected in the face of the potentially dramatic events surrounding the develop­ment and stabilization of a BPF. These patients are often debilitated due to the underlying processes that predispose to the development of a BPF and close attention to the appropriate care of these problems will aid in the management. Appropriate antibiotic therapy of the potentially infected pleural space and adequate drainage of this space require attention. Cultured organisms from the pleural space have included tuberculosis, Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella pneumoniae, Proteus species, Streptococcus viridans, and nonhemolytic Streptococcus, Pneumococcus, and Aspergillus spe­cies. The nutritional status of the patient with a BPF must be maintained.
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