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Bronchopleural Fistulae

  • Andrew Ian LevinEmail author
Chapter

Abstract

Bronchopleural fistulae (BPFs) are air leaks that occur via connections between the airways and pleural space. They may be divided into two broad categories, alveolar-parenchymal-pleural and bronchopleural fistulae when they originate from lung parenchyma or the tracheo-bronchial tree, respectively. Prior to anesthesia induction, anesthesiologists must evaluate not only the absolute size of the fistula but the “effective” size of the fistula. The effective size of the fistula considers both the physical size of the fistula and also the effect of lung mechanics on the distribution of ventilation and fistula gas flow during positive pressure ventilation (IPPV). If IPPV results in preferential gas flow via the fistula, alveolar ventilation could become difficult or impossible. As the total functional residual capacity may be reduced in the presence of a large BPF, hypoxia may rapidly ensue after anesthesia induction particularly if IPPV is ineffective. The safest approach is to determine effective fistula size before anesthesia induction and thereby determine the safest anesthesia induction technique. Small “effective size” fistulae can be managed with conventional induction of anesthesia followed by lung isolation if needed. Fistulae that have a large effective size need a more conservative approach, with maintenance of spontaneous respiration until fistula isolation. These latter goals can be achieved with volatile induction and placement of a double-lumen endotracheal tube; alternatively, awake single-lumen tube intubation may be performed followed by lung isolation prior to commencement of IPPV. Bronchopleural fistulae are increasingly being managed by interventional pulmonologists using minimally invasive techniques, endobronchial valves placement having proved successful on many occasions. The management of BPFs in the ICU is a complex issue, the primary aims being treatment of the underlying lung disease, optimizing IPPV and arterial oxygenation. Management of the air leak using lung isolation or other techniques is usually a secondary aim in the ICU setting.

Keywords

Bronchopleural fistula Lung resection Anesthesia Thoracic surgery Ventilation Lung isolation ICU Double-lumen endobronchial tubes Bronchial blockers Awake intubation Volutrauma VILI Barotrauma 

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Anaesthesiology and Critical CareUniversity of Stellenbosch, Tygerberg HospitalCape TownSouth Africa

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