Outline the strategies for management of a persisting broncho-pleural fistula (BPF) in a mechanically ventilated patient. Include in your answer, where relevant, the advantages and disadvantages of the strategies listed.
Principles of Management:
- Adequate drainage of the fistula with an intercostal catheter of adequate size to manage a large air leak.
- May require multiple catheters, and ability to manage large flow rates.
- Minimise suction.
- Aim is to reduce mean airway pressure to reduce flow through fistula tract.
- Low tidal volume and PEEP.
- Low mandatory breath rate.
- Permissive hypercapnoea.
- Short inspiratory time.
- Attempt to wean to spontaneous breathing mode from mandatory ventilation as soon as practicable and preferably from ventilatory support altogether.
3. Independent Lung Ventilation
- Advantages: - May minimise leak in injured lung whilst preserving gas exchange with conventional parameters in normal lung.
- Disadvantages: -requires some form of double lumen tube – difficult to place and secure.
- May not be tolerated in hypoxic patients.
- Requirement for two ventilators –either synchronous or asynchronous – technically demanding and complex.
4.High Frequency Ventilation
- Advantages are that it may reduce peak air pressures and theoretically reduce air leak.
- Disadvantages - not widely available. Recent evidence suggesting an increase in mortality for this ventilatory technique in ARDS patients.
- Advantages – Definitive management strategy. May be only option to seal leak. Disadvantages – Patient may not be fit enough to tolerate.
6. Endobronchial Occlusion
- Advantages – Widely available, can be definitive treatment.
- Disadvantages – may be technically challenging, not feasible with multiple leaks.
7. Application of PEEP to intercostal catheter
- Advantages – may decrease leak volume and maintain intra-thoracic PEEP.
- Disadvantages – compromise drainage, risk of tension, not feasible with multiple tubes.
- Advantages – may be only option to treat hypoxia.
- Disadvantages – not widely available, complex, little experience.
- large-bore drain
- or, multiple drains
- minimise suction
- low VT
- low PEEP
- low resp rate
- short insp. time
- tolerate high PCO2
- wean rapidly
- extubate early
|Independent lung ventilation
- dual-lumen tube
- or, bronch blocker
|Application of PEEP to the ICC||
Lois, Manuel, and Marc Noppen. "Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management." CHEST Journal 128.6 (2005): 3955-3965.
Baumann, Michael H., and Steven A. Sahn. "Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient." CHEST Journal 97.3 (1990): 721-728.
Pierson, David J., et al. "Management of bronchopleural fistula in patients on mechanical ventilation." (2012) - from UpToDate.