Other maneuvers during both CV and HFV can be potentially helpful in patients with BPF. Selective intubation and CV of the unaffected lung in patients with a unilateral BPF may be useful but will predispose to the collapse of the nonintubated lung. The use of differential lung ventilation with CV may be of benefit in some patients. Additionally, positioning the patient such that the BPF is dependent has been shown in one report to decrease fistula flow.

Case reports and animal studies indicate other potential applications of HFV in BPF. Included is the use of independent lung ventilation, with HFV applied to the BPF lung and CV to the normal lung. Additionally, another mode of HFV, ultra-high-fre­quency jet ventilation, is being explored and has been used with some success particularly in reducing BPF  air leak in both patients and animal models. Inde­pendent lung ventilation with ultra-high-frequency lung ventilation applied to the BPF lung and CV to the normal lung has led to rapid BPF closure in two of the three patients whose cases have been reported.

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High frequency ventilation (HFV) is a generic term applied to several types of ventilation: high frequency positive pressure ventilation, high frequency jet ven­tilation, and high frequency oscillation ventilation.

Complete discussion of the general principles of HFV and specific details of different types and applications of HFV have been detailed elsewhere. Despite mechanical differences in the delivery systems, the basic principles remain the same. Therefore, in the following discussion the term HFV will be used although specific references cited may use one of the different types of HFV.

Despite case reports, animal studies, and clinical studies involving the use of HFV in the setting of BPF, controversy still surrounds the use of HFV in patients with BPFs. The genesis of this controversy results from conflicting reports of the success of HFV in patients with BPFs. However, scrutiny of the literature reveals subgroups of patients with BPFs in whom HFV may be of clinical value and not just a “last ditch” intervention in the face of CV failure.

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As with the chest tube, the resistance to flow of gases is an integral consideration in the choice of the drainage system connected with the chest tube in a patient with a BPF. The size of air leak and the flow that the drainage device can accommodate are necessary considerations when choosing the drainage system. Several drainage devices are commercially available, each with different capabilities (Table 2). A recent review experimentally assessed four of the more commonly used devices: the Sentinel Seal, Thora-Klex, Pleur-Evac, and Emerson Post-Operative Pump. The maximal air flow achievable in these devices ranged from 2.3 to 35.5 L/min with —20 cm H₂0 vacuum. The Emerson and Pleur-Evac systems have lower resistances and can manage air flows of 35.5 L/min and 34.0 L/min, respectively. The level of suction applied to these drainage devices is also important. A level of — 20 cm H₂0 suction provided optimal drainage with an increase to — 40 cm H₂0 not significantly altering flow through the chest tube.

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Patients with chest trauma, adult respiratory dis­tress syndrome (ARDS)-related barotrauma, and pa­tients undergoing invasive chest procedures, including thoracotomy and central line placement, are general categories of patients in whom the potential for the development of a BPF exists and who are fre­quently encountered by the critical care specialist. A chest tube placed to manage a BPF in these patients can be both helpful and detrimental and may play a role far more important than that of a passive conduit (Table 1). Air leaks in these settings range from <1 to 16 L/min and a chest tube capable of permitting prompt and efficient drainage of this level of air flow is necessary. Gas moving through a tube does so in laminar fashion and is governed by Poiseuilles Law. In the clinical situation, the gas moving through a chest tube is likely moist and therefore subject to turbulent flow and governed by the Fanning equation. Therefore, both the length (1) and, more importantly, the radius (r) are important when choosing a chest tube and connecting tubing to adequately evacuate a BPF (flow varies exponentially to the fifth power of the radius of the tube). The smallest internal diameter that will allow a maximum flow rate of 15.1 L/min at —10 cm H₂0 suction is 6 mm, with a No. 32 F chest tube having an internal diameter of 9 mm. Hence, a chest tube with an adequate diameter to convey the poten­tially large air flow of a BPF must be taken into consideration when managing a BPF. A chest tube too small in diameter can lead to lung collapse and tension pneumothorax in the setting of a mobile mediastinum.

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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.

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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.

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