Bronchopleural Fistula occurs when there is a communication between the bronchial airspace and the pleural space. This condition can be very dangerous.
It can be diagnosed by performing a physical exam and ordering imaging tests, such as a CT scan.
The initial management focuses on drainage of the air- and fluid-filled spaces. Antibiotic therapy is instituted and tailored based on culture results.
Causes
A bronchopleural fistula is an abnormal passage between the airways of your lungs (the bronchi) and the space between the membranes that line the lungs (the pleura). It’s a serious complication from lung surgery or cancer treatment that can lead to severe pneumonia and life-threatening fluid leaks. It’s most common after pulmonary resection, but it can occur in other conditions too.
A BPF is a direct communication between the pleural cavity and the bronchial stump and usually occurs in one of the main stem, lobar, or segmental bronchi. It can be central or peripheral based on where it forms. In general, central BPFs form between the pleura and the tracheobronchial three, while peripheral ones are between the pleura and an airway distal to the segmental bronchi or the lung parenchyma.
Typically, a BPF isn’t painful and isn’t diagnosed until it causes symptoms such as fever, coughing up blood or pink frothy fluid, or if you have a chest x-ray that shows a cloudy area on the side of your lung where the bronchopleural fistula formed. The leaking fluid can also cause pneumonia or respiratory distress syndrome (ARDS).
When BPFs are diagnosed, they’re treated with fluid drainage and sealants to prevent further leakage. In some cases, a doctor may decide to remove the bronchial stump.
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The most important step is to avoid lying on the side of your chest with a BPF because that can lead to pus from the pleural cavity leaking into the bronchial stump, contaminating the remaining lung.
If your thoracic surgeon finds a bronchopleural fistula, he or she will probably recommend a procedure called chemical pleurodesis. This involves injecting a silver nitrate solution through a flexible bronchoscope into the bronchial stump to close the fistula. You will likely need to stay in the hospital for a few days while your fistula heals. You’ll have to follow up with your thoracic surgeon to see if you need any further treatments such as surgery or another type of chemical pleurodesis. If you don’t, your bronchopleural fistula may heal on its own within a few weeks.
Diagnosis
A bronchopleural fistula (BPF) is a direct communication between the pleural space and either the tracheobronchial tree or lung parenchyma. It can occur either immediately after surgery or months after it. BPF is a potentially life-threatening complication and requires prompt diagnosis and management. Its early identification is important as it can lead to a rapid decrease in the air content of the chest and an increase of the pleural fluid level. This can result in pulmonary embolism and respiratory distress syndrome. A high index of suspicion for a BPF should be present in patients with a prolonged postoperative air leak or those who develop product cough following pneumonectomy.
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A diagnosis can be made by radiography, a computed tomography scan or bronchoscopy. The radiograph may show a pleural effusion, pneumomediastinum or surgical emphysema. The chest CT scan typically shows a cavitating mass with a reduction in the air and fluid levels of the pleural space. A methylene blue dye can be instilled into the pleural space to confirm the presence of the bronchopleural fistula.
Chest tube placement is the treatment of choice for a person with a bronchopleural fistula. A doctor will insert a tube into the patient’s chest to drain the air and fluid from the pleural space. The patient will then receive broad-spectrum antibiotics to treat the infection.
Bronchopleural Fistula can be treated surgically or by endobronchial occlusion with metallic coils. A new technique involves the use of a flexible catheter to deliver the coils directly to the bronchopleural fistula site. The method has shown promising results in a small pilot study. It is recommended that the coils should be left in place for at least 24 hours to allow for adequate occlusion of the bronchopleural fistula.
A bronchopleural fistula can cause a severe and life-threatening infection. A person with a BPF should be evaluated immediately and should have a high index of suspicion for its presence. A bronchopleural fistula is more common in people with cancer or those who undergo lung surgery, such as lung transplantation. However, it can also be found in healthy people who have an accident or infection of the lung.
Treatment
A bronchopleural fistula (BPF) is an abnormal passage between the lungs’ airways and pleural cavity, which contains fluid in the thoracic chest wall. This complication can be caused by surgery, cancer treatment, or infection. It’s a serious but treatable condition that causes lung pain and coughing with blood, pus, or pinkish frothy fluid. A person who has a BPF needs to stay in the hospital until it’s treated.
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Treatment options vary depending on the size and location of the bronchopleural fistula and the patient’s clinical condition. If the bronchopleural fistula occurs early after surgery, it may be surgically repaired with good results. BPFs that occur later in the postoperative period are harder to treat.
Infection is a common cause of BPF. Treatment focuses on controlling the infection and preventing further soiling of the nonoperative lung. A healthcare professional may place an intercostal drain to collect fluid and air from the pleural space. The healthcare professional may send a sample of the drainage for microbiologic analysis to identify the organisms. They might recommend broad-spectrum antibiotics.
The drainage tube may also be used to prevent air from entering the pleural space through the bronchial stump and causing further contamination or pneumothorax. Alternatively, healthcare professionals may use sclerosants to achieve pleurodesis. These include talc, ethanol, silver nitrate, polyethylene glycol, and bleomycin. These medications must be used with caution in people who have a fistula because they can damage the underlying lung tissue.
In a person with a BPF, a surgeon can surgically repair the bronchial stump and pleural cavity by making a flap of skin or muscle over the wound. They can also use fibrin glue to seal the pleural space and prevent further leakage of fluid. A bronchopleural fistula can also be treated with antibiotics and other medication. The patient must be carefully monitored to make sure the problem doesn’t worsen. It’s important for patients to follow their doctor’s instructions after surgery to prevent a bronchopleural fistula. This can help them get better faster and reduce the risk of complications from the procedure. For example, it’s important to stop smoking and to take the medications as prescribed.
Prevention
Infection is a common cause of Bronchopleural Fistula and can be prevented by covering the bronchial stump in the operating room with sterile dressings. The use of sterile surgical sponges can also reduce the risk of infection in cases where a bronchopleural fistula has already formed. In addition, bronchoscopy with fistula sealing agents and chemical pleurodesis are effective treatments for BPF.
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BPF develops in 0.5-2 percent of patients undergoing lung surgery and can be life-threatening. It is most commonly associated with lobectomy or pneumonectomy, and it can be caused by tuberculosis or other lung diseases.
The symptoms of BPF can range from mild to severe and may include coughing, shortness of breath, and chest pain. BPF can be diagnosed using x-rays, ultrasound, CT scans, and pulmonary function tests. It is important to recognize and treat BPF as soon as possible because it can lead to complications including aspiration pneumonia.
If a patient has BPF, it is important to drain the empyema with tube thoracostomy or open drainage and to administer antibiotics. A chest multislice computed tomographic scan should be performed prior to surgical repair of the BPF to determine the integrity of the pleural space and remaining lung volume. Patients with BPF should be kept on supplemental oxygen to improve oxygenation and nutritional status.
Most recently, interventional radiologists have developed methods to effectively close BPFs. The first approach is to use a bronchoscope and a catheter to inject a fibrin glue into the drainage cavity of the bronchopleural fistula. The fibrin glue can seal the fistula and promote local tissue fibrosis. The technique is relatively safe and has a high success rate, although it requires the assistance of a skilled radiologist to perform.
Another method to treat BPF involves inserting a metallic J or silicon Y stent into the bronchial stump to cover the leak. The stents can be removed after a few weeks to allow the pleural fluid to clear and prevent contamination of the remaining lung. Other techniques involve the use of cardiac occlusive devices that were originally designed to treat congenital heart defects such as atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA). However, these methods are not widely used due to their increased cost and invasiveness.
