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Critical Care Medicine Feb 2021To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of... (Review)
Review
OBJECTIVE
To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of positive-pressure ventilation. To provide guidance of lung isolation, mechanical ventilator, pleural catheter, and endobronchial strategies for the management of bronchopleural fistula on mechanical ventilation.
DATA SOURCES
Online search of PubMed and manual review of articles (laboratory and patient studies) was performed.
STUDY SELECTION
Articles relevant to bronchopleural fistula, mechanical ventilation in patients with bronchopleural fistula, independent lung ventilation, high-flow ventilatory modes, physiology of persistent air leak, extracorporeal membrane oxygenation, fluid dynamics of bronchopleural fistula airflow, and intrapleural catheter management were selected. Randomized trials, observational studies, case reports, and physiologic studies were included.
DATA EXTRACTION
Data from selected studies were qualitatively evaluated for this review. We included data illustrating the physiology of driving pressure across a bronchopleural fistula as well as data, largely from case reports, demonstrating management and outcomes with various ventilator modes, intrapleural catheter techniques, endoscopic placement of occlusion and valve devices, and extracorporeal membrane oxygenation. Themes related to managing persistent air leak with mechanical ventilation were reviewed and extracted.
DATA SYNTHESIS
In case reports that demonstrate different approaches to managing patients with bronchopleural fistula requiring mechanical ventilation, common themes emerge. Strategies aimed at decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure decreases airflow across the bronchopleural fistula.
CONCLUSIONS
Mechanical ventilation and intrapleural catheter management must be individualized and aimed at reducing air leak. Clinicians should emphasize reducing peak inspiratory pressures, reducing positive end-expiratory pressure, and limiting negative intrapleural pressure. In refractory cases, clinicians can consider lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in appropriate patients as well as definitive management with advanced bronchoscopic placement of valves or occlusion devices.
Topics: Bronchial Fistula; Female; Humans; Male; Pleural Diseases; Positive-Pressure Respiration; Ventilators, Mechanical
PubMed: 33372747
DOI: 10.1097/CCM.0000000000004771 -
Turk Gogus Kalp Damar Cerrahisi Dergisi May 2023Although bronchial sleeve resections were previously defined as an alternative technique to pneumonectomy for patients with limited pulmonary reserve, currently these... (Review)
Review
Although bronchial sleeve resections were previously defined as an alternative technique to pneumonectomy for patients with limited pulmonary reserve, currently these resections are applied as a standard even in patients having normal pulmonary capacity. Pneumonectomy, itself, is a disease, and sleeve lobectomies can be performed without compromising oncological principles and without causing significant morbidity and mortality. In parallel with the developments in surgical techniques, bronchial sleeve resections can be performed by videothoracoscopic and robotic surgeries. Major complications in sleeve lobectomies are bronchial dehiscence, bronchopleural fistulas, and broncho-arterial fistulas. Late complications are bronchial stenosis and tumor recurrence.
PubMed: 38344122
DOI: 10.5606/tgkdc.dergisi.2023.24715 -
Therapeutic Advances in Respiratory... 2023Bronchopleural fistula is a potentially fatal disease most often caused after pneumonectomy. Concomitant problems such as pulmonary infection and respiratory failure are... (Review)
Review
Bronchopleural fistula is a potentially fatal disease most often caused after pneumonectomy. Concomitant problems such as pulmonary infection and respiratory failure are typically the main contributors to patient mortality because of the improper contact between the bronchial and pleural cavity. Therefore, bronchopleural fistulas need immediate treatment, which requires the accurate location and timely closure of the fistula. Currently, bronchoscopic interventions, because of their flexibility and versatility, are reliable alternative therapies in patients for whom surgical intervention is unsuitable. Possible interventions include bronchoscopic placement of blocking agents, atrial septal defect (ASD)/ventricular septal defect (VSD) occluders, airway stents, endobronchial valves (EBVs) and endobronchial Watanabe spigots (EWSs). Recent developments in mesenchymal stem cells (MSCs) transplantation technology and three-dimensional (3D) printed stents have also contributed to the treatment of bronchopleural fistula, but more research is needed to investigate the long-term benefits. This review focuses on the effectiveness of various bronchoscopic measures for the treatment of bronchopleural fistula and the directions for future development.
Topics: Humans; Bronchoscopy; Postoperative Complications; Pleural Diseases; Bronchial Fistula; Pneumonia; Pneumonectomy
PubMed: 37067054
DOI: 10.1177/17534666231164541 -
Respirology Case Reports Apr 2021Tuberculous bronchopleural fistula is a rare complication of pulmonary tuberculosis with presentation ranging from patients who are asymptomatic with incidental findings...
Tuberculous bronchopleural fistula is a rare complication of pulmonary tuberculosis with presentation ranging from patients who are asymptomatic with incidental findings on imaging to those who present with acute tension pneumothorax.
PubMed: 33747520
DOI: 10.1002/rcr2.740 -
Cureus Dec 2020A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree or the lung parenchyma. Despite being a rare entity, a BPF may carry a...
A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree or the lung parenchyma. Despite being a rare entity, a BPF may carry a high mortality rate. Symptoms of BPF are often nonspecific and subtle, so a high index of clinical suspicion is essential for its correct diagnosis, with imaging playing an extremely important role both in the diagnosis and in the selection of the most appropriate therapeutic approach for each patient. This paper reports a case of a 60-year-old male admitted to the hospital for an etiological investigation of a unilateral pleural effusion. The patient underwent several procedures, among them a video-assisted thoracic surgery, complicated by a peripheral BPF. Therapeutic approach for BPFs must be adapted to each particular case. In this patient, a conservative approach proved to be effective. Meanwhile, the patient was diagnosed with pleural tuberculosis, being discharged on antibacillary medication and while improving BPF's manifestations.
PubMed: 33489597
DOI: 10.7759/cureus.12187 -
Thoracic Cancer May 2022The purpose of this study was to investigate the results of postoperative bronchopleural fistula repair and to identify adverse factors for its success.
BACKGROUND
The purpose of this study was to investigate the results of postoperative bronchopleural fistula repair and to identify adverse factors for its success.
METHODS
We retrospectively reviewed the surgical results of 39 patients who underwent surgical repair for postoperative bronchopleural fistula between January 2010 and June 2020. Success of bronchopleural fistula repair was defined as the visual closure of the bronchopleural fistula with the absence of an air leak, a recurrence of bronchopleural fistula and infection in the thoracic cavity.
RESULTS
Twenty-five (64.1%) bronchopleural fistulas occurred after pulmonary resection and 14 (35.9%) after lung transplantation. Bronchopleural fistula was diagnosed 19 days (median) and repaired 28 days (median) after the initial operation by primary closure in 27 (69.2%) patients, and by additional resection in 12 (30.8%) patients. The overall success rate was 59% (23/39) and the overall mortality was 56.4% (22/39). Multivariable analysis revealed that the patients who were supported by mechanical ventilation at the time of repair had significantly lower success rates than those without (15.4%, 2/13 vs. 80.8%, 21/26, respectively, p < 0.001). The omental flap group tended to have a better success rate than the muscle flap group (p = 0.07).
CONCLUSIONS
There was a high overall mortality rate after bronchopleural fistula repair and a low success rate. Mechanical ventilation at the time of bronchopleural fistula repair was significantly related to the failure of bronchopleural fistula repair.
Topics: Bronchial Fistula; Humans; Pleural Diseases; Pneumonectomy; Postoperative Complications; Retrospective Studies; Treatment Outcome
PubMed: 35393787
DOI: 10.1111/1759-7714.14404 -
Folia Medica Dec 2019Pleural empyema after pneumonectomy still poses a serious postoperative complication. A bronchopleural fistula is often detected. Despite various therapeutic options... (Review)
Review
INTRODUCTION
Pleural empyema after pneumonectomy still poses a serious postoperative complication. A bronchopleural fistula is often detected. Despite various therapeutic options developed during the last five decades it remains a major surgical challenge.
RESULTS
There is no widely accepted treatment for post-pneumonectomy pleural empyema (PPE) and the management depends mostly on the presence or absence of broncho-pleural fistula (BPF) and the patient’s general condition. In the absence of BPF, the role of surgery is still not clear because of its high morbidity and impossibility to prevent recurrences. In the earlier period, the definitive treatment consisted of open window thoracostomy followed by obliteration of the pleural cavity with antibiotic solution at the time of chest wall closure. Subsequently, the proposed different methods and modifications improved the outcome. There is an association between hospital volume and operative mortality after the lung resection. Hospital volume and the surgeon’s specialty have more influence on the outcome than the individual surgeon’s volume.
CONCLUSIONS
Treatment management of PPE should be individualized. Definitive treatment options comprise aggressive surgery that is not possible in quite a high proportion of impaired patients. Hospital volume, surgeon’s volume and surgeon’s specialty may influence the prognosis.
Topics: Debridement; Empyema, Pleural; Humans; Pneumonectomy; Postoperative Complications; Thoracic Surgery, Video-Assisted
PubMed: 32337865
DOI: 10.3897/folmed.61.e47943 -
The Lancet. Respiratory Medicine Mar 2024It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
It is uncertain whether individualisation of the perioperative open-lung approach (OLA) to ventilation reduces postoperative pulmonary complications in patients undergoing lung resection. We compared a perioperative individualised OLA (iOLA) ventilation strategy with standard lung-protective ventilation in patients undergoing thoracic surgery with one-lung ventilation.
METHODS
This multicentre, randomised controlled trial enrolled patients scheduled for open or video-assisted thoracic surgery using one-lung ventilation in 25 participating hospitals in Spain, Italy, Turkey, Egypt, and Ecuador. Eligible adult patients (age ≥18 years) were randomly assigned to receive iOLA or standard lung-protective ventilation. Eligible patients (stratified by centre) were randomly assigned online by local principal investigators, with an allocation ratio of 1:1. Treatment with iOLA included an alveolar recruitment manoeuvre to 40 cm HO of end-inspiratory pressure followed by individualised positive end-expiratory pressure (PEEP) titrated to best respiratory system compliance, and individualised postoperative respiratory support with high-flow oxygen therapy. Participants allocated to standard lung-protective ventilation received combined intraoperative 4 cm HO of PEEP and postoperative conventional oxygen therapy. The primary outcome was a composite of severe postoperative pulmonary complications within the first 7 postoperative days, including atelectasis requiring bronchoscopy, severe respiratory failure, contralateral pneumothorax, early extubation failure (rescue with continuous positive airway pressure, non-invasive ventilation, invasive mechanical ventilation, or reintubation), acute respiratory distress syndrome, pulmonary infection, bronchopleural fistula, and pleural empyema. Due to trial setting, data obtained in the operating and postoperative rooms for routine monitoring were not blinded. At 24 h, data were acquired by an investigator blinded to group allocation. All analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT03182062, and is complete.
FINDINGS
Between Sept 11, 2018, and June 14, 2022, we enrolled 1380 patients, of whom 1308 eligible patients (670 [434 male, 233 female, and three with missing data] assigned to iOLA and 638 [395 male, 237 female, and six with missing data] to standard lung-protective ventilation) were included in the final analysis. The proportion of patients with the composite outcome of severe postoperative pulmonary complications within the first 7 postoperative days was lower in the iOLA group compared with the standard lung-protective ventilation group (40 [6%] vs 97 [15%], relative risk 0·39 [95% CI 0·28 to 0·56]), with an absolute risk difference of -9·23 (95% CI -12·55 to -5·92). Recruitment manoeuvre-related adverse events were reported in five patients.
INTERPRETATION
Among patients subjected to lung resection under one-lung ventilation, iOLA was associated with a reduced risk of severe postoperative pulmonary complications when compared with conventional lung-protective ventilation.
FUNDING
Instituto de Salud Carlos III and the European Regional Development Funds.
Topics: Adult; Humans; Female; Male; Adolescent; One-Lung Ventilation; Respiration; Continuous Positive Airway Pressure; Lung; Oxygen
PubMed: 38065200
DOI: 10.1016/S2213-2600(23)00346-6 -
Journal of Thoracic Disease Oct 2023
PubMed: 37969259
DOI: 10.21037/jtd-23-1231