Bronchopleural Fistula (BPF)

 

 

Considerations

 

  • Etiology of BPF & associated urgency:

    • Trauma, empyema/abscess, bullous disease, post lung resection, carcinoma

  • Comorbid disease:

    • Chronic obstructive lung disease, malignancy, coronary artery disease, arrhythmias

  • Absolute indication for lung separation:

    • Pathophysiological impact of positive pressure ventilation

      • Ineffective ventilation (with chest tube in place)

      • Tension pneumothorax (without chest tube in place)

      • Systemic air embolus

    • Protection of healthy lung from soiling

  • Repeat thoracotomy considerations:

    • Hemorrhage

    • Sepsis, septic shock

    • Postoperative analgesia

    • Postoperative ICU disposition for PPV

 

 

Goals & Conflicts

 

  • Need for lung isolation prior to PPV in order to prevent pathophysiological complications as outlined above

  • Balanced with possible full stomach, difficult airway, hemodynamic instability, limited functional reserve

  • Rapid sequence lung isolation techniques:

    • Regional anesthesia

    • Awake fibreoptic intubation: single lumen ETT +/- bronchial blocker, double lumen ETT prior to GA

    • Asleep intubation with spontaneous ventilation prior to isolation

    • Modified RSI with no or limited PPV prior to lung isolation

    • Double lumen ETT preferred to bronchial blocker to support suctioning, optimal ventilation & isolation

  • Need for resuscitation & stabilization prior to OR:

    • Fluids, vasopressors, antibiotics, chest tube placement

    • If no chest tube in place prior to OR, thoracic surgeon must be immediately available to place a chest tube

  • Intraoperative goals:

    • Lung protective ventilation

    • Restrictive fluid strategy

    • Maintenance of normothermia & normal metabolics

  • Optimization to facilitate postoperative extubation:

    • Resuscitation

    • Bronchial suctioning

    • Bronchodilators

    • Extubation to BiPAP