Outline the principles of, and strategies for management of a persisting broncho-pleural fistula (BPF) in a mechanically ventilated patient.
Include in your answer the advantages and disadvantages of each strategy.
Principles of Management:
Strategies for Managing Large Leaks:
Examiners Comments:
Answered well. Most candidates could have scored more if they had given greater breath to the strategies used, or greater depth to the strategies they discussed.
This question is identical to Question 23 from the first paper of 2016 and Question 4 from the first paper of 2014, which were done extremely poorly. The fact that in 2019 trainees have almost uniformly passed this question suggests that either some sort of fistula epidemic has made it a topical matter on everybody's mind, or that writing practice answers to previous exam questions is a valid exam preparation strategy.
In brief:
Strategy | Advantages | Disadvantages |
Drainage - large-bore drain - or, multiple drains - minimise suction |
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Ventilator strategy: - low VT - low PEEP - low resp rate - short insp. time - tolerate high PCO2 - wean rapidly - extubate early |
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Independent lung ventilation - dual-lumen tube - or, bronch blocker |
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Surgical repair |
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Bronchial stenting |
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Bronchial occlusion |
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Application of PEEP to the ICC |
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HFOV |
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ECMO |
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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.
Mueller, Michael Rolf, and Beatrice A. Marzluf. "The anticipation and management of air leaks and residual spaces post lung resection." Journal of thoracic disease 6.3 (2014): 271.
Cerfolio, Robert J., et al. "A prospective algorithm for the management of air leaks after pulmonary resection." The Annals of thoracic surgery 66.5 (1998): 1726-1730.