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:
- 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.
- Ventilatory management
- 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.
- General measures
- Standard ICU supportive management
- Broad spectrum antibiotic cover
- Attention to nutritional requirements – patients usually catabolic.
Strategies for Managing Large Leaks:
- 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.
- 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.
- Endobronchial Occlusion
- Advantages – Widely available, can be definitive treatment.
- Disadvantages – may be technically challenging, not feasible with multiple leaks.
- 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
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.
- 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||
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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.