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Bronchopleural Fistula

Bronchopleural fistula is an anomalous connection between the bronchial and pleural cavity. It is unusual and occurs often secondary to resection of the lung for malignancies, although there are several other known etiologies for this condition. It is difficult to diagnose and is associated with a high incidence of mortality.


Presentation

Bronchopleural fistula (BPF) is a rare condition which presents a diagnostic and therapeutic challenge to physicians and is often fatal [1]. It is defined as an atypical communication between the bronchial and pleural cavities.

BPF can be classified on the basis of the duration of symptoms as acute, subacute or chronic and on the basis of etiology as accidental (penetrating chest wall wounds) [2] or iatrogenic (lung resection), secondary to malignancies, and infections [3]. Approximately 25% of BPF occur after lung resection surgery, especially for malignant pulmonary tumors [2]. In these patients, BPF typically presents post chemotherapy or in advanced stages, the fistula develops from the operated lobectomy stump. Other causes of BPF include parenchymal pleural fibroelastosis [4], tuberculosis [5], chemotherapy and radiation [1].

Pre-operative risk factors for the development of BPF are steroid administration, H.influenzae infection, fever, anemia, leukocytosis, tracheostomy and bronchial lavage for clearance of mucus plugs [6]. BPF following lung resection typically occurs within two weeks of the surgery. If it presents early (in acute cases) i.e. in the first few postoperative days, then it could be due to inadequate closure or breakdown of the anastomoses. These patients present with a cough with purulent expectoration, emphysema in the subcutaneous tissues, hypotension, and dyspnea. On examination, a mediastinal shift is noted.

Subacute and chronic BPF occur in immunocompromised or debilitated patients who present with long-standing productive cough, debility, malaise, wasting and fever. Chronic infection can lead to fibrosis within the pleural cavity.

Surgical Procedure
  • The surgical procedure performed was chosen according to the degree of infection in the empyema cavity.[ncbi.nlm.nih.gov]
  • Traditional surgical procedures include chronic open drainage, attempts at direct stump closure, thoracoplasty with or without chest wall muscle transposition and trans-sternal bronchial closure.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: It suggested that the ENBL may be an alternative interventional treatment for bronchopleural fistula treating other than surgical procedure.[ncbi.nlm.nih.gov]
  • The surgical procedure, preoperative therapy, complications after surgery, right side, patient age, past history, and tumor residuals were mentioned as risk factors of bronchopleural fistula.[ncbi.nlm.nih.gov]
  • (Section: Anesthetic Management for Specific Surgical Procedures, Subsection: Bronchopleural Fistula.) In: Miller Anesthesia. 7th edition. Saunders; 2009. PubMed[openanesthesia.org]
Atrial Septal Defect
  • A recent case report described the endobronchial closure of a BPF through the implantation of an Amplatzer ASD device, commonly used for transcatheter closure of atrial septal defects.[ncbi.nlm.nih.gov]
  • We describe the successful treatment of a multidrug-resistant tuberculosis patient with BPF using an occlusion device originally designed for transcatheter closure of an atrial septal defect.[ncbi.nlm.nih.gov]
  • Matitiau A, Birk E, Kachko L, et al: Transcatheter closure of secundum atrial septal defects with the Amplatzer septal occluder: early experience. Isr Med Assoc J 2001;3:32-35.[karger.com]
  • Jude Medical, Plymouth, Minnesota, United States) is a self-expandable, double-disk device designed for the occlusion of atrial septal defects. The device is made of braided nitinol and interwoven polyester to promote occlusion and tissue in-growth.[jtd.amegroups.com]
  • Endoscopic treatment of tracheobronchial tree fistulas using atrial septal defect occluders: preliminary results. J Bras Pneumol. 2009;35:1156-60. [ Links ] 15 Tedde ML, Minamoto H, Scordamaglio PR, et al.[scielo.br]
Chest Discomfort
  • CASE REPORT The patient presented in the current case report is a 40-year-old previously healthy woman who presented with a 5-year history of chronic cough, right-sided chest discomfort, and dyspnea associated with back pain, and lower leg pain.[ncbi.nlm.nih.gov]
  • Low rates of fever and chest discomfort were observed. Our patient experienced a significant reduction in air leak size after the administration of fibrin sealant through a fiberoptic bronchoscope, despite lengthy chest tube trials and blebectomy.[ajhp.org]
  • Major side effects reported were fever (12.5%) and chest discomfort (4.1%). In our case, the persistent air leak resulted as a complication of an empyema.[najms.org]
Chronic Cough
  • CASE REPORT The patient presented in the current case report is a 40-year-old previously healthy woman who presented with a 5-year history of chronic cough, right-sided chest discomfort, and dyspnea associated with back pain, and lower leg pain.[ncbi.nlm.nih.gov]
  • DOI: 10.12691/ajmcr-5-9-4 Published online: September 15, 2017 Abstract This case report highlights a 55 year old gentleman of Malay descent who presented to the hospital with chronic cough, dyspnoea and night sweats.[pubs.sciepub.com]
Lower Leg Pain
  • CASE REPORT The patient presented in the current case report is a 40-year-old previously healthy woman who presented with a 5-year history of chronic cough, right-sided chest discomfort, and dyspnea associated with back pain, and lower leg pain.[ncbi.nlm.nih.gov]
Suggestibility
  • Although prompt resurgery is strongly suggested for early onset large fistulas, the clinical scenario may suggest a cautious conduct and conservative treatment could be advocated and repeated.[ncbi.nlm.nih.gov]
  • Clinical follow-up of 1.5 years without recurrence suggests initial safety and feasibility of this approach. Further assessment of MSC grafts in these difficult clinical scenarios requires expanded study.[ncbi.nlm.nih.gov]
  • Increased gas in the pneumonectomy operative bed, or new gas within a loculated effusion are highly suggestive of the diagnosis. Infectious causes include tuberculosis, Actinomyces israelii, Nocardia, and Blastomyces dermatitidis.[en.wikipedia.org]
  • CONCLUSIONS: It suggested that the ENBL may be an alternative interventional treatment for bronchopleural fistula treating other than surgical procedure.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: Our experience strongly suggests that the sacrifice of the PA branch to the spared lobe is a possible risk factor for anastomotic complications for a sleeve lobectomy after induction CRT.[ncbi.nlm.nih.gov]
Fear
  • Bronchopleural fistula (BPF) is a feared postoperative complication of pneumonectomy that carries significant morbidity and mortality. BPF can be treated by various surgical and medical techniques.[ncbi.nlm.nih.gov]
  • […] present: (1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others (2) the person's response involved intense fear[books.google.ro]
  • However, fearing a marked decline in cardiopulmonary function, the patient did not wish to undergo resection surgery. Figure 1 Chest CT course before final admission.[springerplus.springeropen.com]
  • A known side effect of MB is the blue discoloration of skin and green pigmentation of body fluids. 10,11 Caution must be used in patients who are G6PD deficient as severe hemolysis has been reported. 12 A feared complication of intravenous MB is serotonin[journals.lww.com]
  • . ** Provider hesitation is a nice term for all the reasons providers sometimes fail to seek mental health referrals for patients; such as fear of embarrassing our patients, believing that counseling is only needed for psychiatric emergencies, failure[thoracics.org]
Confusion
  • Four months later, however, she was readmitted for investigation of confusion and pink expectorations.[ncbi.nlm.nih.gov]
  • Persistent bronchopleural air leak would be a more descriptive term, and would avoid confusion from the common implications of inflammation and suppuration associated with the word fistula in surgery and other settings.[ahcmedia.com]

Workup

BPF diagnosis can present a dilemma as it is often difficult to localize the fistula and its origin. The workup may necessitate repeated bronchoscopic as well as imaging procedures for detection of the condition [7]. Flexible bronchoscopy is useful for diagnosis as well as therapy [2] as it enables visualization of the fistula, obtain samples for microbiological evaluation, detect infectious etiologies and perform therapeutic procedures [8].

Plain X-ray chest is one of the first radiological tests to be performed and is likely to show a hydropneumothorax.

Other imaging procedures like methylene blue bronchography and computed tomography (CT) are performed as part of the workup with CT scan being considered the gold standard test for diagnosis of BPF and its etiology [9]. Findings on CT include an air-fluid level, hydropneumothorax or pneumothorax or a pneumomediastinum with mediastinal shift, a fistulous tract along with the underlying pulmonary pathology or tumor.

Xenon ventilation scintigraphy can also help to detect a BPF [10] [11] [12].

Pneumoperitoneum
  • We report a case of a complete right lower lobe bronchial stump reopening, successfully treated by pneumoperitoneum.[ncbi.nlm.nih.gov]
  • Pneumoperitoneum Pneumoperitoneum is the injection of air into the abdominal cavity, causing an elevation of the hemi-diaphragm and thus reducing the residual pleural space postoperatively.[shc.amegroups.com]
  • Alternative agents mentioned in the literature included tetracycline and silver nitrate Pneumoperitoneum is an option discussed by Mueller & Marzluf (2014) ; essentially the dome of the diaphragm on the affected side is punctured so that some gas can[derangedphysiology.com]
Actinomyces Israelii
  • Infectious causes include tuberculosis, Actinomyces israelii, Nocardia, and Blastomyces dermatitidis. Malignancy and trauma can also result in the abnormal communication.[en.wikipedia.org]

Treatment

  • BPF orifices were closed in five patients after receiving 5 treatments with carbolic acid, 1 patient received 2 treatments, 1 patient was given 3 treatments, 2 patients received 4 treatments and 3 patients were given 7 treatments.[ncbi.nlm.nih.gov]
  • Bronchoscopic treatment can be repeated, and if it fails, does not preclude subsequent successful surgical treatment. Copyright 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.[ncbi.nlm.nih.gov]
  • The pleural effusion and bronchopleural fistula resolved following immunosuppressive treatment for six months.[ncbi.nlm.nih.gov]
  • Most published papers deal with endoscopic and surgical treatment. We report our experience with conservative management.[ncbi.nlm.nih.gov]
  • Previous nonsurgical treatments for bronchopleural fistula have had limited success.[ncbi.nlm.nih.gov]

Prognosis

  • Pulmonary aspergillus empyema with bronchopleural fistula is a rare and severe disease with a poor prognosis.[ncbi.nlm.nih.gov]
  • Short-term ( CONCLUSION: Endobronchial closure of BPF using both types of Amplatzer occluders (AD and AVP) is a minimally invasive effective modality of treatment with high safety profile and satisfactory long-term outcome considering the poor prognosis[ncbi.nlm.nih.gov]
  • With prompt recognition and conservative treatment, it's likely that the prognosis of bronchopleural fistulas will improve.[verywellhealth.com]
  • Prognosis depends on the amount of air leak; patients with smallest air leak have the best prognosis. [6] BPF in patients with suppurative pleuro-plumonary diseases are initially managed conservatively with dependent drainage, reduction of the pleural[apicareonline.com]

Etiology

  • Other imaging procedures like methylene blue bronchography and computed tomography (CT) are performed as part of the workup with CT scan being considered the gold standard test for diagnosis of BPF and its etiology.[symptoma.com]
  • RESULTS: The main etiology for BPF was surgery (n 24), pneumonectomy (n 14) or lobectomy/segmentectomy (n 10). The underlying disease was either primary (n 19) or metastatic (n 2) lung cancer.[ncbi.nlm.nih.gov]
  • The underlying etiologies were left pneumonectomy and right lower video-assisted lobectomy for non-small-cell lung cancer. The sizes of the fistulas were 6 mm and 3 mm in diameter, respectively.[ncbi.nlm.nih.gov]
  • Pathology They are usually divided as: central: when the fistula involves the trachea or a lobar bronchus peripheral: when a distal airway, either segmental bronchi or the lung parenchyma, communicates to the pleural space Etiology post-operative complication[radiopaedia.org]
  • The incidence, etiology, and prevention of postresectional bronchopleural fistula. Semin Thorac Cardiovasc Surg. 2001;13:3–7. PubMed Google Scholar 2. Haraguchi S, Koizumi K, Hioki M, et al.[link.springer.com]

Epidemiology

  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev. 2015;28:603-61. doi: 10.1128/CMR.00134-14. [PubMed] [Free full text] Kunyoshi V, Cataneo DC, Cataneo AJ.[apicareonline.com]
  • Epidemiology The incidence of varies from 4.5% to 20% after pneumonectomy and 0.5% after lobectomy.[wikidoc.org]
Sex distribution
Age distribution

Pathophysiology

  • This case is an example of what may be a unique pathophysiologic mechanism of bronchopleural fistula formation--a 'stress rupture' of the lung parenchyma following lung volume reduction surgery.[ncbi.nlm.nih.gov]
  • Baumann et al (1990) - an overview of BPF in the mechanically ventilated patient Pierson et al (2015) - an UpToDate article on this topic, for the paying customer These resources have been remixed and pruned to form the summary made available below: Pathophysiology[derangedphysiology.com]
  • Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev. 2015;28:603-61. doi: 10.1128/CMR.00134-14. [PubMed] [Free full text] Kunyoshi V, Cataneo DC, Cataneo AJ.[apicareonline.com]
  • Pathophysiology and management of one-lung ventilation. ThoracSurgClin. 2005;15(1):85-103. [PubMed][apicareonline.com]

Prevention

  • OBJECTIVE: To reduce the incidence of postpneumonectomy local recurrence, and to prevent the onset of bronchopleural fistula.[ncbi.nlm.nih.gov]
  • Abstract Bronchopleural fistula (BPF) is a well recognized and potentially fatal complication of major thoracic surgery and several strategies regarding its prevention and subsequent management have been described.[ncbi.nlm.nih.gov]
  • The therapy of esophagopleural and bronchopleural fistula is long-term and complicated, requiring a multidisciplinary approach and several basic principles must be adhered to the management including treatment of infection and prevention of sepsis, local[ncbi.nlm.nih.gov]
  • First, open-window thoracostomy was undertaken to control the septic state and to prevent aspiration of infected pleural fluid.[ncbi.nlm.nih.gov]
  • Numerous types of flap coverage have been reported to prevent or to repair bronchopleural fistulas. Most of the flaps were harvested from chest area.[ncbi.nlm.nih.gov]

References

Article

  1. Sonobe M, Nawkagawa M, Ichinose M, et al. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg. 2000;18:519–23.
  2. Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128:3955–65
  3. Bhardwaj N, Kundra A, Garcea G. Bronchopleural fistula following laparoscopic liver resection.BMJ Case Rep. 2014 Oct 9;2014
  4. Becker CD, Gil J, Padilla ML. Idiopathic pleuroparenchymal fibroelastosis: an unrecognized or misdiagnosed entity?. Mod. Pathol. 2008;21 (6): 784-7.
  5. Westcott JL, Volpe JP. Peripheral bronchopleural fistula: CT evaluation in 20 patients with pneumonia, empyema, or postoperative air leak. Radiology. 1995;196 (1): 175-81.
  6. Chawla RK, Madan A, Bhardwaj PK, Chawla K. Bronchoscopic management of bronchopleural fistula with intrabronchial instillation of glue (N-butyl cyanoacrylate). Lung India. 2012 Jan-Mar; 29(1): 11–14
  7. Sarkar P, Chandak T, Shah R, Talwar A. Bronchopleural fistula following laparoscopic liver resection.Indian J Chest Dis Allied Sci. 2010 Apr-Jun;52(2):97-104
  8. Ellis JH, Sequeira FW, Weber TR, Eigen H, Fitzgerald JF. Balloon catheter occlusion of bronchopleural fistulae. Am J Roentgenol. 1982;138:157–59.
  9. Stern EJ, Sun H, Haramati LB. Peripheral bronchopleural fistulas: CT imaging features. AJR Am J Roentgenol. 1996;167 (1): 117-20.
  10. Hollett P, Wright E, Wesolowski C, et al. Aerosol ventilation scintigraphy in the evaluation of bronchopleural fistula: a case report and literature review. Can J Surg. 1991;34 (5): 465-7.
  11. Ali SA, Hogge M, Cesani F. Localization of a bronchopleural fistula in a postpneumonectomy patient using ventilation scintigraphy. Clin Nucl Med. 1995;20 (10): 943.
  12. Pigula FA, Keenan RJ, Naunheim KS, et al. Diagnosis of postpneumonectomy bronchopleural fistula using ventilation scintigraphy. Ann. Thorac. Surg. 1995;60 (6): 1812-4.

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Last updated: 2019-06-28 10:43