1. Dr Chiranjib Bhattacharyya
Associate Professor
Dept. Of Anaesthesiology
IPGMER KOLKATA

2.  Communication
between bronchial tree
and pleural space
 High morbidity and mortality
 Prolonged hospital stay
 No standard treatment guidelines or
consensus
 Aetiology :
1.postoperative – 2/3
2.non-operative – 1/3

3. CLASSIFICATION OF AIR
LEAKS
 Alveolopleural
fistula(APF):pulmonary-pleural
communication distal to segmental
bronchus, common after lung
resection except
pneumonectomy, heal conservatively.
 BPF: communication between a
mainstem, lobar or segmental
bronchus and the pleura lined
cavity, usually require surgical
intervention

4.  4.5%-20% after pneumonectomy and 0.5% after lobectomy
 Predisposing factors:
1.h `Rt.pneumonectomy
2. Uncontrolled pleural/pulmonary infection
3. Preop. radiation,steroid,cirrhosis,diabetes
4. Uncorrected low serum albumin, anaemia
5. Malignancy
6. Contd.mechanical ventilation for more than 24h
7. H influenzae in sputum
8. Fever, high ESR

5.  Main bronchus,intermdt bronchus has higher risk
compared to lobar bronchus
 Long bronchial stump, residual tumour, excessive
peribronchial and paratracheal dissection-harmful
 Routine coverage of stump with
omentum, intercostal muscle flap, pleural
flap, pericardial fat esp after right pneumonectomy
suggested

6. NONPOSTOPERATIVE BPF
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Infection- pneumonia, lung abscess,TB,empyema
ARDS
Persistent spontaneous pneumothorax
Thoracic trauma
Iatrogenic eg line placement,lung biopsy,pleural
biopsy bronchoscopy
Necrotising lung disease associated with
radiation,chemotherapy
Spontantaneous rupture of bulla,cyst
Erosion of bronchial wall:
malignancy,FB,chr.inflammation

7. CLINICAL
PRESENTATION
o
o
o
o
o
Usually 7-15 days following a lung
resection
Early (1-7days ), intermediate ( 8-30 days )
and late ( more than 30 days )
As complication of pleuropulmonary
infection-any time during the course of the
illness
Early indicators: reappearance of
fever,increased cough with
purulent/serosanguinous sputum
Persistent bubbling from the chest drain

8. CLINICAL PRESENTATION (CONTD)
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
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ACUTE: sudden onset of
dyspnoea,cough,expectoration of purulent
material,hypotension,subcutn.emphysema,shifting of
trachea and mediastinum.
SUBACUTE: insidious onset of
fever,malaise,wasting,minimally productive cough
CHRONIC: associated with infectious disease,minimal
mediastinal shift due to pleural and mediastinal
fibrosis,not life threatening,adequate gas exchange in
healthy lung
Systemic features of sepsis

9. POST-PNEUMONECTOMY CXRS
Day 2
Day 1
Day 14
Day 30
Radiographics 2006;26:1449-1468

10. ACUTE POST-PNEUMONECTOMY BPF
Day 22
Reappearance of air
OR a drop in airfluid level >1.5cm
Subcutaneous or
mediastinal
emphysema
Tension pneumothorax
& Pulmonary flooding
Mediastinal
shift
Contralateral lung
consolidation
from
transbronchial
spill
Radiographics 2006;26:1449-1468

11. DIAGNOSIS
 CLINICAL
 Persistent air leak: >24h after
development of pneumothorax
 Exclude other causes of persistent air
leak:
1.an external air leak
2.extrathoracic location of side
holes
3.disconnections

12. DIAGNOSIS (CONTD.)
 Plain x-rays may reveal following
features of BPF :
1.steady increase in intrapleural
airspace
2.appearance of a new air fluid level
(indicates level of the BPF)
4.development of tension
pneumothorax
5.drop in air fluid level exceeding
2cm (in absence of chest tube )

13. DIAGNOSIS CONTD.
 Role of CT Scan: demonstrates
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pneumothorax,pneumomediastinum,underlyin
g lung pathology
Demarcation of actual fistulous
communication
Role of FOB: can confirm and localise the
BPF
FOB and selective bronchography
Visualisation of continuous return of air
bubbles on bronchial wash
Selective instillation of methylene blue into
segmental bronchi: appears in chest
drain,sputum

14.  FOB aided placement of balloon-tipped catheter
in selective airway: inflation of balloon eliminates
leak
 Combined FOB and Capnography : polyurethane
catheter passed through br.scopic channel and
introduced into different bronchi
 BPF suggested by loss of capnographic tracing:
affected bronchus communicates to atmosphere
through chest tube

15. BPF WITH FISTULA OPENING BEING
VISIBLE ON FOB

16. Post pneumonectomy bronchopleural fistula, (A)
right hydropneumothorax, (B) FOB showed a possible fistulous
opening at the right bronchial stump, (C) methylene
Blue injected at the suspected site, (D) appearance of dye
in the pleural drainage system confirmed the diagnosis.

17. DIAGNOSIS (CONTD.)
 Changes in gas concentration in pneumonectomy
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cavity after inhalation of different conc. of O2,N2O
Ventilation scintigraphy using radioactive
gases, eg.
133Xe that accumulate in pleural space within and
remain trapped in the pleural space in washout
study
High incidence of false negative results
Inhalation of radio-labelled aerosols with planar
and SPECT imaging: requires patient
cooperation, false positives occur, direct estimation
of size of BPF not possible

18.  1.The
largest(C): continued bubbling through
chest tube,least common,pts on
mech.ventilation
 2.The 2nd largest(I): air leak only during
inspiration,pts on mech. ventilation with
large APF or small BPF
 3.The 3rd largest(E): air leak only during
expiration,after lung surgery due to APF
 4.The smallest(FE): air leak only during
forced expiration eg. coughing,common after
lung resection
 Small leaks heal with underwater drains but
larger leaks may require suction

19. CONSEQUENCES OF BPF

 Persistent pneumothorax: air escaping through
the BPF delays healing of the tract
 Inadequate ventilation: significant loss of TV
 Pendelluft: seen in early BPF when mediastinum
is mobile
 V/Q mismatch
 Infection of pleural space
 Most common cause of death in BPF: aspiration
pneumonia and ARDS,tension pneumothorax

20. PROBLEMS WITH LARGE BPF IN ICU
Difficult to wean from ventilator
Inability to apply PEEP
Failure to expand the remaining lung
Hypoxia, hypercarbia
May need dual ventilation
May need HFV
High mortality: occurrence of BPF during
mechanical ventilation identifies pts. with high
mortality

21. TREATMENT OF BPF
 Treatment options include: surgical
procedures,medical therapy,bronchoscopic- guided
placement of glue,coils,sealants etc
 Initial treatment: control of life-threatening
conditions
 Tension pneumothorax: urgent insertion of
chestdrain
 Pulmonary flooding: immediate airway
control,postural drain with affected side down
 Major bronchial stump dehiscence: immediate
resuture with reinforcement

22. TREATMENT (CONTD)
 Aggressive management of underlying
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comorbidities
Haemodynamically unstable pt. with varying
degrees of resp. failure
Superadded sepsis
Poor nutrition, hypoalbunaemia, anaemia
Unresolved empyema, underlying
tubercular/fungal infection
Poor candidates for a second surgical procedure
Need care in ICU setup

23. TREATMENT ( CONTD.)
o Drainage of pleural space with proper
antimicrobial coverage
o Enteral or parenteral nutrition
o Correction low albumin and haematocrit
o Mechanical ventilatory support if required

24. ROLE OF CHEST TUBE IN BPF
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Indicated in all pts. with high flow BPF and
drainage of empyema
Add positive intrapleural pressure during expiration
to reduce air leak and maintain PEEP
Intermittent occlusion during inspiratory phase to
decrease BPF flow
Useful in patients with ARDS
Can function as foreign body and delay healing
Predispose to infection at insertion site and pleural
space

25. CHEST TUBE (CONTD.)
 Loss
of tidal volume
 Abnormal gas exchange
 Inappropiate ventilator cycling
 Tube should of sufficient diameter to allow
free drainage of air leak
 Flow varies with 5th power of tube radius in
clinical situations due to turbulent flow of
moist air( Fanning equation )
 Pleurodesis: sclerosing agent eg
bleomycin can be passed through tube

26.  Air leaks may range from 1-16L/min
 Loss of effective TV and PEEP, incomplete lung
expansion,CO2 retention, auto-triggering of
ventilator, severe hyperventilation
 Excess use of sedatives, muscle relaxants
 Goal: 1. keep airway pressure at or below critical
opening pressure of fistula
2.adequate pleural space decompression to allow
lung re-expansion

27. Increased chest tube suction increases flow through
BPF, so use least possible pressure or none at all
 Limiting the amount of PEEP during ventilation
 Limiting effective tidal volume
 Shortening the inspiratory time
 Reducing the respiratory rate
 Reducing the proportion of minute volume supplied
by ventilator
 Differential lung ventilation using a DLT
 Independent lung ventilation using 2 ventilators


28. HIGH FREQUENCY VENTILATION IN BPF
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Results are conflicting
More useful in pts. with normal lung
parenchyma and proximal BPF
Can be useful in pts. with massive air leak
Have been successfully used in pts. with
bilateral BPF
Less effective in pts. with bilaterally diseased
noncompliant lungs
Major handicap: doesn’t allow isolation of lungs

29. THERAPEUTIC BRONCHOSCOPY IN BPF
o Allows inspection of the stump
o Confirms location and size of the BPF
o Bronchoscopy aided application of sealant substance
can be tried
o Intrabronchial stents, valves,embolisation coils etc
have been used
o Suitable for small fistulas ( <5mm diam )
o Proximally located fistula-mainstem, lobar or
segmental bronchi are more suitable
o Useful alternative in patients not proper candidates
for surgery

30. SURGICAL PROCEDURES IN BPF
• Decortication of lung
• Revision of bronchial stump
• Closure of fistula with muscle flap
from intercostal space
• Thoracoplasty combined with pedicle
muscle flap to cover bronchial stump
• Resection of diseased chronically
infected lung segments

31.  Experienced
thoracic anaesthesiologist
 Problems in anaesthesia for BPF pts.:
 1.Isolation of the healthy lung reqd.
 2.Prevention of tension pneumothorax during
PPV
 3.Inadequate ventilation due to loss of gas
through fistula
 4.Significant intraoperative blood loss
 5.Patient preparation may be suboptimal
 6.Early extubation and avoidance of
postoperative PPV desirable

32. Assessment of possible loss of TV through the
fistula:
 bubble flow through chest drain continous or
intermittent
 Quantification of size of BPF: inhaled TV– exhaled
TV
 Nonintubated pt.: tight fitting mask and fast
responding spirometer
 Intubated pt.: direct attachment of spirometer to
ETT
 Larger the leak,greater need to isolate BPF by lung
isolation
 Devices: DLT,SLT,independent bronchial blocker


33. ANAESTHESIA FOR BPF (CONTD.)
 DLT advantages:
 1.most secure method of isolation
 2.allows easy bilateral suction and ventilation
 3.differential lung ventilation possible
 DLT disadvantage: most difficult to place in awake patients
under topical anaesthesia of airway
 SLT disadvantage:

1.doesnt allow easy suction or ventilation of affected
lung

2. not designed for endobronchial use

3.if placed in R mainstem bronchus will obstruct
orifice of RUL

34. ANAESTHESIA FOR BPF (CONTD.)
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Bronchial blocker advantages:
1.can be deflated to suction or ventilate BPF lung
2.allows lobar isolation
Disadvantage: least secure method of lung isolation
Ability to deliver PPV must be assessed
Working chest drain prior to induction
SLT safe to use: if fistula small, chronic,uninfected
DLT best choice for PPV: if significant airleak present
Usual MV can be delivered to healthy lung,no loss
through fistula and no risk of contamination on
turning the pt.

35. ANAESTHESIA FOR BPF (CONTD.)

o Emergency situation: SLT can be used,provides
protection and ventilation to healthy lung
o Non pneumonectomy pt.: BB can be placed through
ETT into mainstem bronchus of affected side,less
stable,less protection to the healthy lung
o Post pneumonectomy pt.: BB is not an option due to
short length of bronchial stump available
o Anaesthetic management options include:
o
1.awake fibreoptic intubation with SLT,DLT or BB.
o Induction of GA after lung isolation is achieved

36. ANAESTHESIA FOR BPF (CONTD.)

 Safest method but technically most difficult
 Requires excellent pt. cooperation and thorough airway
topical anaesthesia

2.Induction of GA maintaining spont.ventilation using
deep inhalational anaesthesia
 PPV avoided lungs are isolated
 Breath holding and laryngospasm may nessecitate
unplanned use of PPV
 Vigorous coughing in either technique may provoke
spillover into healthy lungs and reopen a fistula
 Significant hypotension can occur in elderly,debilitated
pts.

37. 3.If airway is thought to be easy, rapid sequence
induction can be done avoiding PPV until lung
isolation.
 Position for induction: head up position maintained
as long as possible with 30deg lateral tilt keeping
diseased lung down
 Post pneumonectomy pts.; DLT or SLT placed under
direct vision with help of FOB for accurate
placement and avoiding injury to bronchial stump
 Suction of chest tube to be avoided during
induction: to reduce loss of TV with PPV


38. Chest open, SLT used, excessive air leak: lungs packed
off and manual compression of fistula by surgeon
 Rigid bronchoscope can be introduced under topical
anaesthesia of airways or inhalation anaesthesia:
observation of fistula, suction,positioning of
endobronchial tube or BB, jet ventilate the healthy lung
 Extubation: as soon as feasible as neg. pr. ventilation is
best
 Bronchial tree examined with FOB before extubation


39. ANAESTHESIA FOR BPF (CONTD.)
If postop ventilation is necessary
DLT is not changed
Thoracic epidural analgesia for post
operative analgesia
TEA has been used as sole
anaesthetic technique in BPF closure
in elderly debilitated pts.

40. REFERENCES
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Sarkar P et al Diagnosis and Management
Bronchopleural Fistula Indian J Chest Allied
Sci 2010;52:97-104
Manuel L et al Bronchopleural Fistulas An
Overview of the Problem With Special Focus on
Endoscopic Mnagement CHEST 2005;128:39553965
Sanjay O P et al Management of Bronchopleural
Fistula. Core Topics in Thoracic Anaesthesia
Chapter 27,OUP 2009
Principles and Practice of Anaesthesia for
Thoracic Surgery.ed P Slinger 2011 Pg 467-71