Chest
Volume 128, Issue 6, December 2005, Pages 3955-3965
Journal home page for Chest

Reviews
Bronchopleural Fistulas: An Overview of the Problem With Special Focus on Endoscopic Management

https://doi.org/10.1378/chest.128.6.3955Get rights and content

A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality. By far, the postoperative complication of pulmonary resection is the most common cause, followed by lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis. The treatment of BPF includes various surgical and medical procedures, and of particular interest is the use of bronchoscopy and different glues, coils, and sealants. Localization of the fistula and size may indicate potential benefits of surgical vs endoscopic procedures. In high-risk surgical patients, endoscopic procedures may serve as a temporary bridge until the patient's clinical status is improved, while in other patients endoscopic procedures may be the only option. Therapeutic success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current therapeutic options seem to be complementary, and the treatment should be individualized.

Section snippets

Definition and Incidence

BPFs are communications between the pleural space and the bronchial tree. Although rare, they represent a challenging management problem and are associated with an important morbidity. After pulmonary resection, BPFs can be a life-threatening condition.

The incidence has been reported from 1.5 to 28% after pulmonary resection.1234 This variability apparently depends on the etiology, surgical technique, and experience of the surgeon.567 It seems that the incidence is lower for benign conditions

Etiologies

The etiologies are varied (Table 1).8910111213 By far, postoperative complication for pulmonary resection is the most common cause, followed by necrotic lung complicating infection, chemotherapy or radiotherapy (for lung cancer), persistent spontaneous pneumothorax, and tuberculosis (less common).1141516 Most recently, Sato and colleagues17 reported their experience with postoperative BPF; they found BPF in 5 of 64 cases (7.8%) of inflammatory diseases and 19 of 481 cases (4%) of lung cancer.

In

Clinical Presentation

The clinical presentation is variable and is divided into acute, subacute, and delayed or chronic forms. When acute, BPF can be a life-threatening condition due to tension pneumothorax or asphyxiation from pulmonary flooding. The presentation is characterized by the sudden appearance of dyspnea, hypotension, subcutaneous emphysema, cough with expectoration of purulent material or fluid, shifting of the trachea and mediastinum, persistence of air leak in the absence of a technical problem, or

Diagnosis

Several methods have been used to diagnose BPFs, including the instillation of methylene blue into the pleural space19 and bronchography.1920 Although 133Xe often is no longer used, Zelefsky et al21 demonstrated small leaks using 133Xe in a gaseous state in a ventilation study. In the presence of a fistula, 133Xe activity accumulates in the pleural space and remained trapped within the pleural space on the washout study. Other gases have been used such as 81mKr and 99mTc diethylenetriamine

Prognosis

BPF, or bronchopleural air leak, is regarded as an ominous complication of ventilator management in acute respiratory failure. Mortality reports have been variable as stated earlier, but data on its natural course and prognosis are lacking. Pierson et al15 reported their experience with all cases of mechanical ventilation at a major trauma center during a 4-year period. They found that 39 of the 1,700 patients receiving mechanical ventilation had BPFs lasting at least 24 h. Overall mortality in

Treatment

Treatment options of BPF include surgical procedures as well as medical therapy, and in particular the use of bronchoscopy and different glues, coils, and sealants. Success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current interventions seem to be complementary and that treatment should be individualized.

Bronchoscopy is indicated to exclude injury to the proximal airways. Initial nonoperative management focuses on decreasing the

Discussion

There are no controlled studies comparing the different sealants or comparing surgical and endoscopic therapy. In general, the endoscopic procedure is preferred in high-risk surgical candidates to avoid the risk of anesthesia and surgery. The only study65 found to specifically address the value of bronchoscopic sealing of BPFs was a retrospective study in which cases of 45 patients seen over a 13-year period with BPF after pneumonectomy (40 patients) or lobectomy (5 patients) were reviewed. In

Conclusions

Clearly, further studies are required to establish the role of techniques and patient selection for endoscopic procedures, as well as which technique or combination will be most valuable. There are no established guidelines in the proper management of patients with BPF or even a consensus on how to approach the problem. Further research in these areas may shed light into the best therapy for this difficult problem.

References (83)

  • JC Baldwin et al.

    Treatment of bronchopleural fistula after pneumonectomy

    J Thorac Cardiovasc Surg

    (1985)
  • KS Miller et al.

    Chest tubes: indications, technique, management and complications

    Chest

    (1987)
  • JB Downs et al.

    Treatment of bronchopleural fistulas during continuous positive pressure ventilation

    Chest

    (1976)
  • PB Blanch et al.

    A new device that allows synchronous intermittent inspiratory chest tube occlusion with any mechanical ventilator

    Chest

    (1990)
  • EW Swenson et al.

    Resistance to airflow in bronchospirometric catheters

    J Thorac Surg

    (1957)
  • JL Ratliff et al.

    Endobronchial control of bronchopleural fistulae

    Chest

    (1977)
  • P Carvalho et al.

    Management of bronchopleural fistula with a variable-resistance valve and a single ventilator

    Chest

    (1997)
  • JK Chowdhury

    Percutaneous use of fiberoptic bronchoscope to investigate bronchopleurocutaneous fistula

    Chest

    (1979)
  • OP Mathew et al.

    Selective bronchial obstruction for the treatment of bullous interstitial emphysema

    J Pediatr

    (1980)
  • R Lan et al.

    Fiberoptic bronchial blockade in a small bronchopleural fistula

    Chest

    (1987)
  • JL Ratliff et al.

    Endobronchial control of bronchopleural fistula

    Chest

    (1977)
  • K Takaoka et al.

    Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol

    Chest

    (2002)
  • JW Menard et al.

    Endoscopic closure of bronchopleural fistulas using a tissue adhesive

    Am J Surg

    (1988)
  • M Torre et al.

    Endoscopic gluing of bronchopleural fistula

    Ann Thorac Surg

    (1987)
  • RE Wood et al.

    Endoscopic management of large, postresection bronchopleural fistulae with methacrylate adhesive (Super Glue)

    J Pediatr Surg

    (1992)
  • EL York et al.

    Endoscopic diagnosis and treatment of postoperative bronchopleural fistula

    Chest

    (1990)
  • C Jessen et al.

    Use of fibrin glue in thoracic surgery

    Ann Thorac Surg

    (1985)
  • W Glover et al.

    Fibrin glue application through the flexible fiberoptic bronchoscope: closure of bronchopleural fistulas

    J Thorac Cardiovasc Surg

    (1987)
  • T Kinoshita et al.

    Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax

    Chest

    (2000)
  • PM McCarthy et al.

    The effectiveness of fibrin glue sealant for reducing experimental pulmonary air leak

    Ann Thorac Surg

    (1988)
  • PH Hollaus et al.

    Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases

    Ann Thorac Surg

    (1998)
  • WR Martin et al.

    Closure of a bronchopleural fistula with bronchoscopic instillation of tetracycline

    Chest

    (1991)
  • JE Heffner et al.

    Clinical efficacy of doxycycline for pleurodesis

    Chest

    (1994)
  • J Sprung et al.

    Treatment of a bronchopleural fistula with a Fogarty catheter and oxidized regenerated cellulose (Surgicel)

    Chest

    (1994)
  • DP Jones et al.

    Gelfoam occlusion of peripheral bronchopleural fistulas

    Ann Thorac Surg

    (1986)
  • CJ Salmon et al.

    Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula

    Chest

    (1990)
  • RB Ponn et al.

    Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils

    Ann Thorac Surg

    (1993)
  • JM Albes et al.

    Tracheal stenting for malignant tracheoesophageal fistula

    Ann Thorac Surg

    (1994)
  • HG Colt et al.

    Double stents for carcinoma of the esophagus invading the tracheobronchial tree

    Gastrointest Endosc

    (1992)
  • L Freitag et al.

    Management of malignant esophagotracheal fistulas with airway stenting and double stenting

    Chest

    (1996)
  • MH Baumann et al.

    The clinician's perspective on pneumothorax management

    Chest

    (1997)
  • Cited by (0)

    View full text