1. Bronchopleural fistula
Sudhir Rao
Respiratory

2. What ? How ?
Communication between the bronchial tree and the pleural space
Common aeitiology- pulmonary resection
lung necrosis complicating-
infection
chemotherapy
radiotherapy
persistent spontaneous pneumothorax
tuberculosis
lung neoplasm
blunt & penetrating lung injuries chest tube drains/ thoracocentesis

3. Risk factors, incidence & mortality
Peri-operative risk factors-
Pre- operative- fever, steroid use, Haemophilus infuenzae in sputum. Elevated ESR & anemia
Post-operative- fever, steroid use, pre-operative chemo-radiotherapy, leukocytosis, tracheostomy & bronchoscopy for mucus plugging
Other- residual tumor at the resection margins, long bronchial stump, tightness of sutures, excessive peribronchial and paratracheal dissection, ARDS, invasive chest procedures & underlying debilitating disorders ( diabetes, malnutrition, pneumonia, lung abscess, severe COPD with bullous disease)
Incidence-
Following pulmonary resection- 2-5% (< 1% after lobectomy; < 12.5% after pneumonectomy)
Almost always occur within 3 months after surgery
Mortality rates – %; Most common causes-
aspiration pneumonia & subsequent ARDS
tension pneumothorax

4. How do they present? Acute- sudden SOB, BP subcutaneous emphysema
cough with expectoration of purulent material and fluid
persistent air leak
 or disappearence of pleural effusion on Chest X-ray (in Post-operative cases)
Subacute-
wasting, malaise, fever and cough
Chronic-
(usually associated with an infectious process)- there is fibrosis of pleural space and mediastinum, typically preventing mediastinal shift

5. Diagnosis Bronchoscopy- Direct visualization Selective bronchography
Instillation of methylene blue
Capnography to identify the bronchial segment related to BPF[ end tidal CO2 is measured by connecting a capnograph to a polyethylene catheter passed through the bronchoscopic channel- absence of capnographic tracing suggesting communication to air, suggests BPF { disconnect chest tube from UWSD}
CT scan- to identify underlying cause
CT bronchography- injecting 20-30ml Omnipaque into suspected fistula site
Ventilating scintigraphy using 133Xe as the preferred agent [sensitivity 83%, specificity 100%]

6. Management
Adequate pleural drainage & placing patient with the affected side down
Air-leaks range <1-16l/min requires large-bore chest tube (e.g a 32F tube)
Major stump dehiscence- immediate resuture and reinforcement of the bronchial stump
Treatment of infection
Proper nutrition
Surgical closure successful in 80-95%
Surgical techniques- Chronic open drainage
Direct stump closure with intercostal muscle reinforcement
Omental flap
Trans-sternal bronchial closure
Thoracoplasty with or without extrathoracic chest wall muscle transposition

7. Non-surgical management
In spontaneous primary or secondary pneumothorax with persistent leak-
observe for 4 days for spontaneous closure
if air-leak persists for > 4 days – surgical closure indicated
additional chest-drain or  of suction pressure NOT indicated
Patient’s condition too poor for surgery
Small fistula (3-5mm diameter)
Bronchoscopic treatment with fistula closure successful > 1/3 rd of patients
Sealing compounds – lead shot, absolute alcohol, polyethylene glycol, cyano-acrylate glue, fibrin glue, blood clot, antibiotics (tetracycline, doxycycline), albumin glutaraldehyde tissue adhesive, cellulose, gel foam, balloon catheter occlusion, silver nitrate, calf bone etc.
Intra-bronchial valves, vascular embolisation coils
Stents
Watanabe Spigots

9. Thankyou