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

7 May

Mechanically Ventilated Patient

Bronchopleural fistulas (BPFs), communications be­tween the bronchial tree and the pleural space, continue to present a formidable management and therapeutic challenge. A review of BPF is presented and includes discussion of the causes of BPF, clinical presentation, and management with emphasis on currently available medical techniques. Medical man­agement includes appropriate chest tube placement, selection of the drainage device, ventilator selection and use, and diagnostic and therapeutic bronchoscopy.

Etiology and Clinical Presentation

Despite a complex etiology, certain clinical settings, including tuberculosis and pulmonary surgical proce­dures, continue to be associated with and predispose to the occurrence of BPF. Approximately two thirds of BPFs are related to surgery, while the remaining are related to tuberculosis, pneumonia, empyema, and lung abscess. Surgical procedures associated with the development of a BPF include partial or complete pneumonectomy, segmentectomy, and wedge resec­tions of the lung. Bronchopleural fistulas were more common before the decline in the incidence of pul­monary tuberculosis, but the association continues.Tuberculous fistulas occur both after pulmonary re­sections for tuberculosis and spontaneously. Re­gardless of the origin, the overall mortality of patients with BPFs remains high, varying from 18 percent to 50 percent.

The presentation of a BPF has often been defined with regard to a temporal relationship with antecedent surgery as occurring either early or late postopera­tively and is affected by the development of a fibrotic, fixed pleural space and mediastinum. Broncho­pleural fistulas are frequently, but not always, associ­ated with an infected pleural space. In the setting of chronic infection, pleural space and mediastinal fibro­sis can occur with fixation of the mediastinum which can affect the clinical presentation of a patient who develops a BPF. Early postoperative BPFs may have a dramatic presentation because the mediastinum is mobile and predisposes to contralateral shift and compromise of remaining lung function. A late BPF arises in a complicated fibrotic postpneumonectomy space that impedes the development of a tension pneumothorax due to a fixed mediastinum. Viagra Super Active

Bronchopleural fistulas may present acutely or sub- acutely and are influenced by the presence of pleural space infection. The acute presentation of a BPF is frequently heralded by the sudden expectoration of potentially infected material from the pleural space due to airway communication. The exudate may flood the airways of both the affected and contralateral side leading to acute respiratory compromise. Patients with a BPF may also present acutely with a tension pneumothorax prior to the development of a fixed mediastinum. Subacutely, the patient with a BPF may present with an insidious deterioration marked by fever and minimally productive cough. Both surgically and nonsurgically related BPFs can present acutely or subacutely.