Bronchopleural - PowerPoint Presentation

Slide1

Bronchopleural fistula

Sudhir

Rao

Respiratory Slide2

What ? How ?

Communication between the bronchial tree and the pleural space

Common

aeitiology

- pulmonary resection

lung

necrosis complicating-

infection

chemotherapy

radiotherapy

persistent

spontaneous pneumothorax

tuberculosis

lung

neoplasm

blunt

& penetrating lung

injuries

chest

tube drains/

thoracocentesis

Slide3

Risk factors, incidence & mortality

Peri

-operative risk factors-

Pre- operative- fever, steroid use,

Haemophilus

infuenzae

in sputum. Elevated ESR & anemia

Post-operative- fever, steroid use, pre-operative chemo-radiotherapy, leukocytosis, tracheostomy & bronchoscopy for mucus plugging

Other- residual tumor at the resection margins, long bronchial stump, tightness of sutures, excessive

peribronchial

and

paratracheal

dissection, ARDS, invasive chest procedures & underlying debilitating disorders ( diabetes, malnutrition, pneumonia, lung abscess, severe COPD with bullous disease)

Incidence-

Following pulmonary resection- 2-5% (< 1% after lobectomy; < 12.5% after

pneumonectomy

)

Almost always occur within 3 months after surgery

Mortality rates – 18- 67%; Most common causes-

aspiration pneumonia & subsequent ARDS

tension

pneumothoraxSlide4

How do they present?

Acute-

sudden

SOB,



BP

subcutaneous

emphysema

cough

with expectoration of purulent material and fluid

persistent

air leak



or

disappearence

of pleural effusion on Chest X-ray (in Post-operative cases)

Subacute

-

wasting

, malaise, fever and cough

Chronic-

(

usually associated with an infectious process)- there is fibrosis of pleural space and mediastinum, typically preventing

mediastinal

shiftSlide5

Diagnosis

Bronchoscopy- Direct visualization

Selective

bronchography

Instillation

of methylene blue

Capnography

to identify the bronchial segment related to BPF[ end tidal CO2 is measured by connecting a

capnograph

to a polyethylene catheter passed through the

bronchoscopic

channel- absence of

capnographic

tracing suggesting communication to air, suggests BPF { disconnect chest tube from UWSD}

CT scan- to identify underlying cause

CT

bronchography

- injecting 20-30ml

Omnipaque

into suspected fistula site

Ventilating

scintigraphy

using 133Xe as the preferred agent [sensitivity 83%, specificity 100%]Slide6

Management

Adequate pleural drainage & placing patient with the affected side down

Air-leaks range <1-16l/min requires large-bore chest tube (

e.g

a 32F tube)

Major stump dehiscence- immediate

resuture

and reinforcement of the bronchial stump

Treatment of infection

Proper nutrition

Surgical closure successful in 80-95%

Surgical techniques- Chronic open drainage

Direct stump closure with intercostal muscle reinforcement

Omental

flap

Trans

-sternal bronchial closure

Thoracoplasty

with or without

extrathoracic

chest wall muscle transpositionSlide7

Non-surgical management

In spontaneous primary or secondary pneumothorax with persistent leak-

observe for 4 days for spontaneous closure

if air-leak persists for > 4 days – surgical closure indicated

additional

chest-drain or



of suction pressure NOT indicated

Patient’s condition too poor for surgery

Small fistula (3-5mm diameter)Bronchoscopic treatment with fistula closure successful > 1/3 rd of patients Sealing compounds – lead shot, absolute alcohol, polyethylene glycol, cyano-acrylate glue, fibrin glue, blood clot, antibiotics (tetracycline, doxycycline), albumin glutaraldehyde tissue adhesive, cellulose, gel foam, balloon catheter occlusion, silver nitrate, calf bone etc. Intra-bronchial valves, vascular embolisation coils Stents Watanabe SpigotsSlide8
Slide9

Thankyou