Chest
ReviewsBronchopleural Fistulas: An Overview of the Problem With Special Focus on Endoscopic Management
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.
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