Bronchopleural fistula

Published on 07/02/2015 by admin

Filed under Anesthesiology

Last modified 07/02/2015

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Bronchopleural fistula

Glenn E. Woodworth, MD

A bronchopleural fistula is a connection between the bronchi or lung parenchyma and the pleural space. If the fistula communicates with the surface of the chest, it is a bronchopleural cutaneous fistula. Communication between the airways and the pleural space substantially increases the risk of infection and can make ventilation difficult, accounting for the high morbidity associated with this condition. Anesthesia providers may encounter patients with bronchopleural fistulas when these patients present for surgical repair of the fistula or in the intensive care unit when the patients require ventilator management of the condition. In rare cases, a patient may present to the operating room for surgery in which the fistula is an incidental condition.

Etiology

Common causes of bronchopleural fistula include trauma and infection; fistulas may also occur as a postoperative complication of lung surgery. The mechanism is usually rupture or erosion of a lung abscess, bronchus, bulla, cyst, suture line, or parenchymal tissue into the pleural space; however, by far the most common cause is a complication of thoracic surgery. The incidence of postoperative formation of a bronchopleural fistula has been reported to be 2% to 40% after pulmonary resection. Persistent air leak, sepsis, empyema, purulent sputum, and respiratory distress characterize such fistulas. Predisposing factors include perioperative radiation or chemotherapy, residual neoplasm, age greater than 60 years, infection at the resection site, and an avascular bronchial stump.

Treatment

Treatment of bronchopleural fistulas is highly dependent on the cause and nature of the fistula. In general, attempts are made to reduce the pleural space and seal the fistula by either placing a chest tube or performing pleurodesis. In those patients who are intubated, ventilator management is critical to give the fistula the best chance of healing. If the fistula is large (e.g., disruption of a postpneumonectomy bronchial stump), conservative management is often not effective, and surgical intervention will be necessary.

Anesthetic considerations

The primary clinical concern when caring for patients undergoing surgical repair of bronchopleural fistulas relates to providing adequate alveolar gas exchange during positive-pressure ventilation. The following must be considered.

• Tidal volume is preferentially delivered into the pleural space through the low-resistance fistula.

• Air leak into the pleural space can produce a tension pneumothorax.

• Healthy lung tissue should be protected from contamination by the infected lung.

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