Red Book - Bronchopleural Fistula

Question 1

Define an air leak

Answer 1

Any extrusion of air from a normally gas flled cavity such as gthe airway/sinus, GI

Question 2

Classift Air leaks

Answer 2

Cerfolio Class:

Continuous - throughout resp cycle - seen in MV with BPF

Insp

Exp (common after pulmonary surgery)

Forced expiration

Anatomical classification - central or peripheral

Question 3

What is a BPF

Answer 3

Abnormal communication betweeh bronchial tree and the pleural space

Leads to air leak, persistant and failure to inflate lung

Small ones - heal with conservative Tx
Larger - wont

Question 4

Causes of a BPF

Answer 4

Commonly following pulmonary resection (pneumonectomy > lobectomy)

Risks

Right sided procedures
Pleural/pulmonary infection
Pre-op steroid/radiation/DM
Malignancy
MV > 24 hours

Other causes
trauma
ARDS
Infections
Necrotising lung disease
Iatrogenic - lines/drains
Mechanical vent

Question 5

Features of BPF

Answer 5

Dyspnoea
Hypotension
Sub cut emphysema
Cough with prurelence

Tracheal shift
Persistant air leak
Bubbing in the drain

Question 6

Diagnosis of BPF

Answer 6

CXR - increased pleural airspace
fluid level
tension Ptx

Bronch - confirms location, bubbles on washing
methylene blue into drain

CT chest - characterise the BPF

Others - VQ scan

Question 7

Why is BPF different from PTx

Answer 7

BPF is direct communciation between central bronchial tree and pleura

Pneumothorax - peripheral between ruptured bleb and cavity

Question 8

Physiological issues with BPF

Answer 8

Cant apply PEEP
Loss of tidal volume
Cant expand lung
Inapprorpirate cycling

DELAYED WEAN

Question 9

Management

Answer 9

Principles

Resus

General Conservative measures

Ventilatory strategy

Large leak management

Question 10

Resus of BPF

Answer 10

Supportive care and monitor
Imaging

Treat the life threatening - PTx
Dehiscience of stump
Pulmonary flooding and drainage

Question 11

Conservative measures

Answer 11

Large bore drain

Suction to pleural if needed

Abx and drainage

Question 12

Ventilation strategy

Answer 12

Minimise distension and volume

Reduce PEEP, Tv, Insp time and RR

Allow permissive CO2

GET TO SPONTANEOUS VENT SOON

STOP MECHANICAL VENT ASAP

This will encourage healing

Question 13

Options for large leaks

Answer 13

Other vent modes - HFV/Oscillate??

DLT and two vent ventilation, lung isolation

Bronchoscopic repair if <8mm

Sealants

Surgery - thoracoplasy, stump staple, pleural abrasion

ECMO