Bronchopleural Fistulas

An Overview of the Problem With Special Focus on Endoscopic Management
      A bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Although rare, BPFs represent a challenging management problem and are associated with high morbidity and mortality. By far, the postoperative complication of pulmonary resection is the most common cause, followed by lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis. The treatment of BPF includes various surgical and medical procedures, and of particular interest is the use of bronchoscopy and different glues, coils, and sealants. Localization of the fistula and size may indicate potential benefits of surgical vs endoscopic procedures. In high-risk surgical patients, endoscopic procedures may serve as a temporary bridge until the patient's clinical status is improved, while in other patients endoscopic procedures may be the only option. Therapeutic success has been variable, and the lack of consensus suggests that no optimal therapy is available; rather, the current therapeutic options seem to be complementary, and the treatment should be individualized.

      Abbreviations::

      BPF ( bronchopleural fistula), HFV ( high-frequency ventilation), PEEP ( positive end-expiratory pressure)
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      References

        • McManigle JE
        • Fletcher GL
        • Tenholder MF
        Bronchoscopy in the management of bronchopleural fistula.
        Chest. 1990; 97: 1235-1238
        • Cerfolio RJ
        The incidence, etiology and prevention of postresectional bronchopleural fistula.
        Semin Thorac Cardiovasc Surg. 2001; 13: 3-7
        • Sirbu H
        • Busch T
        • Aleksic I
        • et al.
        Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors and management.
        Ann Thorac Cardiovasc Surg. 2001; 7: 330-336
        • Turk AE
        • Karanas YL
        • Cannon W
        • et al.
        Stage closure of complicated bronchopleural fistulas.
        Ann Plastic Surg. 2000; 45: 560-564
        • al-Kattan K
        • Cattelani L
        • Goldstraw P
        Bronchopleural fistula after pneumonectomy for lung cancer.
        Eur J Cardiothorac Surg. 1995; 9: 479-482
        • Conlan AA
        • Lukanich JM
        • Shutz J
        • et al.
        Elective pneumonectomy for benign lung disease: modern day mortality and morbidity.
        J Thorac Cardiovasc Surg. 1995; 110: 1118-1124
        • Sato M
        • Saito Y
        • Nagamoto N
        • et al.
        An improved method of bronchial stump closure for prevention of bronchopleural fistula in pulmonary resection.
        Tohoku J Exp Med. 1992; 168: 507-513
        • Williams NS
        • Lewis CT
        Bronchopleural fistula: a review of 86 cases.
        Br J Surg. 1976; 63: 520-522
        • Abouasaleh R
        • Halaweh O
        • Pichurko B
        Barrett's esophagitis-related bronchoesophageal fistula: the diagnostic value of persistent air leak in the ventilated setting [abstract].
        Chest. 2003; 124: 265S
        • Ford MA
        • Mueller PS
        • Morgenthaler TI
        Bronchoesophageal fistulae secondary to broncholithiasis: a case series.
        Chest. 2003; 124: 146S-147S
        • Richardson JV
        • George RB
        Bronchopleural fistula and lymphocytic empyema due toHistoplasma capsulatum.
        Chest. 1997; 112: 1130-1132
        • Jenkins IR
        • Raymond R
        Boerhaave's syndrome complicated by a large bronchopleural fistula.
        Chest. 1994; 105: 964-965
        • Tsou E
        • Yeager Jr, H
        • Katz S
        Late bronchopleural fistula andHaemophilus influenzaeempyema complicating longstanding oleothorax: report of two cases.
        Chest. 1978; 74: 573-575
        • Malave G
        • Foster ED
        • Wilson JA
        • et al.
        Bronchopleural fistula: present day study of an old problem.
        Ann Thorac Surg. 1971; 11: 1-10
        • Pierson DJ
        • Horton CA
        • Bates PW
        Persistent bronchopleural fistula air leak during mechanical ventilation: a review of 39 cases.
        Chest. 1986; 90: 321-323
        • Hankins JR
        • Miller JE
        • Attar S
        • et al.
        Bronchopleural fistula: 13 year experience with 77 cases.
        J Thorac Cardiovasc Surg. 1978; 76: 755-762
        • Sato M
        • Saito Y
        • Fujimura S
        • et al.
        Study of postoperative bronchopleural fistulas: analysis of factors related to bronchopleural fistulas.
        Nippon Kyobu Geka Gekkai Zasshi. 1989; 37: 498-503
        • Sonobe M
        • Nawkagawa M
        • Ichinose M
        • et al.
        Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer.
        Eur J Cardiothorac Surg. 2000; 18: 519-523
        • Hsu JT
        • Bennett GM
        • Wolff E
        Radiologic assessment of bronchopleural fistula with empyema.
        Radiology. 1972; 103: 41
        • Steiger Z
        • Wilson RF
        Management of bronchopleural fistulas.
        Surg Gynecol Obstet. 1984; 158: 267-271
        • Zelefsky MN
        • Freeman LM
        • Stern H
        A simple approach to the diagnosis of bronchopleural fistula.
        Radiology. 1977; 124: 843
        • Schandevyl VW
        • Bossuyt RB
        Demonstration of a bronchopleural communication by inhalation of Kr-81m gas.
        Clin Nucl Med. 1981; 6: 117-119
        • Nielsen KR
        • Blake LM
        • Mark JB
        • et al.
        Localization of bronchopleural fistula using ventilation scintigraphy.
        J Nucl Med. 1994; 35: 867-869
        • Ricci ZJ
        • Haramati LB
        • Rosembaum AT
        • et al.
        Role of computed tomography in guiding the management of peripheral bronchopleural fistula.
        J Thorac Imaging. 2002; 17: 214-218
        • Alifano M
        • Sepulveda S
        • Mulot A
        • et al.
        A new method for detection of postpneumonectomy broncho-pleural fistulas.
        Ann Thorac Surg. 2003; 75: 1662-1664
        • ACCP consensus panel
        Management of spontaneous pneumothorax.
        Chest. 2001; 119: 590-602
        • Stamatis G
        • Freitag L
        • Wencker M
        • et al.
        Omentopexy and muscle transposition: two alternative methods in the treatment of pleural empyema and mediastinitis.
        Thorac Cardiovasc Surg. 1994; 42: 225-232
        • Hollaus PH
        • Huber M
        • Lax F
        • et al.
        Closure of bronchopleural fistula after pneumonectomy with pedicled intercostals muscle flap.
        Eur J Cardiothorac Surg. 1999; 16: 181-186
        • Cooper WA
        • Miller JI
        Management of bronchopleural fistula after lobectomy.
        Semin Thorac Cardiovasc Surg. 2001; 13: 8-12
        • Baldwin JC
        • Mark JBD
        Treatment of bronchopleural fistula after pneumonectomy.
        J Thorac Cardiovasc Surg. 1985; 90: 813-817
        • Miller KS
        • Sahn SA
        Chest tubes: indications, technique, management and complications.
        Chest. 1987; 91: 258-264
        • Downs JB
        • Chapman RL
        Treatment of bronchopleural fistulas during continuous positive pressure ventilation.
        Chest. 1976; 69: 363-366
        • Gallagher TJ
        • Smith RA
        • Kirby RR
        • et al.
        Intermittent inspiratory chest tube occlusion to limit bronchopleural cutaneous air leaks.
        Crit Care Med. 1976; 4: 328-332
        • Blanch PB
        • Koens Jr, JC
        • Layon AJ
        A new device that allows synchronous intermittent inspiratory chest tube occlusion with any mechanical ventilator.
        Chest. 1990; 97: 1426-1430
        • Swenson EW
        • Birath G
        • Ahbeck A
        Resistance to airflow in bronchospirometric catheters.
        J Thorac Surg. 1957; 33: 275-281
        • Zimmerman JE
        • Colgan DL
        • Mills M
        Management of bronchopleural fistula complicating therapy with positive en expiratory pressure (PEEP).
        Chest. 1973; 64: 526-529
        • Ratliff JL
        • Hill JD
        • Tucker H
        • et al.
        Endobronchial control of bronchopleural fistulae.
        Chest. 1977; 71: 98-99
        • Phillips YY
        • Lonigan RM
        • Joyner LR
        A simple technique for managing a bronchopleural fistula while maintaining positive pressure ventilation.
        Crit Care Med. 1979; 7: 351-353
        • Bauman MH
        • Sahn SA
        Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient.
        Chest. 1990; 97: 721-728
        • Carvalho P
        • Thompson WH
        • Riggs R
        • et al.
        Management of bronchopleural fistula with a variable-resistance valve and a single ventilator.
        Chest. 1997; 111: 1452-1454
        • Carlon GC
        • Cole R
        • Klain M
        • et al.
        High frequency positive pressure ventilation in the management of a patient with bronchopleural fistula.
        Anesthesiology. 1980; 52: 160-162
        • Shen NH
        • Lu FL
        • Wu HW
        • et al.
        Management of tension pneumatocele with high-frequency oscillatory ventilation.
        Chest. 2002; 121: 184
        • Sabanathan S
        • Richardson J
        Management of postpneumonectomy bronchopleural fistula.
        J Cardiovasc Surg. 1994; 35: 449-457
        • Chowdhury JK
        Percutaneous use of fiberoptic bronchoscope to investigate bronchopleurocutaneous fistula.
        Chest. 1979; 75: 203-204
        • Ellis JH
        • Sequeira FW
        • Weber TR
        • et al.
        Balloon catheter occlusion of bronchopleural fistulae.
        AJR Am J Roentgenol. 1982; 138: 157-159
        • Mathew OP
        • Thatch BT
        Selective bronchial obstruction for the treatment of bullous interstitial emphysema.
        J Pediatr. 1980; 96: 475-477
        • Regel G
        • Sturm JA
        • Neumann C
        • et al.
        Occlusion of bronchopleural fistula after lung injury: a new treatment by bronchoscopy.
        J Trauma. 1989; 29: 223-226
        • Lan R
        • Lee C
        • Tsai Y
        • et al.
        Fiberoptic bronchial blockade in a small bronchopleural fistula.
        Chest. 1987; 92: 944-946
        • Hartmann W
        • Rausch V
        A new therapeutic application of the fiberoptic scope [letter].
        Chest. 1977; 71: 237
        • Ratliff JL
        • Hill J
        • Tucker H
        • et al.
        Endobronchial control of bronchopleural fistula.
        Chest. 1977; 71: 98-99
        • Takaoka K
        • Inoue S
        • Ohira S
        Central bronchopleural fistulas closed by bronchoscopic injection of absolute ethanol.
        Chest. 2002; 122: 374-378
        • Hoffberger DS
        • Walsh F
        • Sommers E
        • et al.
        Utilization of a synthetic absorbable sealant activated by helium cadmium laser bronchoscopy for successful closure of a persistent bronchopleural fistula following lobectomy.
        Chest. 2003; 124: 290S-S291
        • Menard JW
        • Prejean CA
        • Tucker WY
        Endoscopic closure of bronchopleural fistulas using a tissue adhesive.
        Am J Surg. 1988; 155: 415-416
        • Roksvaag H
        • Skalleberg L
        • Nordberg C
        • et al.
        Endoscopic closure of bronchial fistula.
        Thorax. 1983; 38: 696-697
        • Torre M
        • Chiesa G
        • Ravini M
        • et al.
        Endoscopic gluing of bronchopleural fistula.
        Ann Thorac Surg. 1987; 43: 295-297
        • Parthasarathi B
        Bronchosopic endobronchial sealing: a novel technique of treating bronchopleural fistula (BPF) [abstract].
        Chest. 2003; 124: 147S
        • Wood RE
        • Lacey SR
        • Azizkhan RG
        Endoscopic management of large, postresection bronchopleural fistulae with methacrylate adhesive (Super Glue).
        J Pediatr Surg. 1992; 27: 201-202
        • York EL
        • Lewall DB
        • Hirji M
        • et al.
        Endoscopic diagnosis and treatment of postoperative bronchopleural fistula.
        Chest. 1990; 97: 1390-1392
        • Jessen C
        • Sharma P
        Use of fibrin glue in thoracic surgery.
        Ann Thorac Surg. 1985; 39: 521-524
        • Glover W
        • Chavis TV
        • Daniel TM
        • et al.
        Fibrin glue application through the flexible fiberoptic bronchoscope: closure of bronchopleural fistulas.
        J Thorac Cardiovasc Surg. 1987; 93: 470-472
        • Onotera RT
        • Unruh HW
        Closure of post-pneumonectomy bronchopleural fistula with fibrin sealant.
        Thorax. 1988; 43: 1015-1016
        • Kinoshita T
        • Miyoshi S
        • Katoh M
        • et al.
        Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax.
        Chest. 2000; 117: 790-795
        • Vietri F
        • Tosato F
        • Passaro U
        • et al.
        The use of human fibrin glue in fistulous pathology of the lung [in Italian].
        Giornale di Chirugia. 1991; 12: 399-402
        • McCarthy PM
        • Trastek VF
        • Bell DG
        • et al.
        The effectiveness of fibrin glue sealant for reducing experimental pulmonary air leak.
        Ann Thorac Surg. 1988; 45: 203-205
        • Hollaus PH
        • Lax F
        • Janakiev D
        • et al.
        Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.
        Ann Thorac Surg. 1998; 66: 923-927
        • Martin WR
        • Siefkin AD
        • Allen R
        Closure of a bronchopleural fistula with bronchoscopic instillation of tetracycline.
        Chest. 1991; 99: 1040-1042
        • Heffner JE
        • Standerfer RJ
        • Torstveit J
        • et al.
        Clinical efficacy of doxycycline for pleurodesis.
        Chest. 1994; 105: 1743-1747
        • Potaris K
        • Mihos P
        • Gakidis I
        Preliminary results with the use of an albumin-glutaraldehyde tissue adhesive in lung surgery.
        Med Sci Monit. 2003; 9: P179-P183
        • Iannettoni JI
        Closure of bronchopleural fistulas using albumin-glutaraldehyde tissue adhesive.
        Ann Thorac Surg. 2004; 77: 326-328
        • Sprung J
        • Krasna MJ
        • Yun A
        • et al.
        Treatment of a bronchopleural fistula with a Fogarty catheter and oxidized regenerated cellulose (Surgicel).
        Chest. 1994; 105: 1879-1881
        • Jones DP
        • David I
        Gelfoam occlusion of peripheral bronchopleural fistulas.
        Ann Thorac Surg. 1986; 42: 334-335
        • Islam SU
        • Beamis JF
        • Choi IS
        Successful closure of a bronchopleural fistula with platinum vascular occlusion coils and N-Butyl-cyanoacrylate glue.
        Chest. 2003; 124: 292S-293S
        • Salmon CJ
        • Ponn RB
        • Westcott JL
        Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula.
        Chest. 1990; 98: 233-234
        • Ponn RB
        • D'Agostino RS
        • Stern H
        • et al.
        Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils.
        Ann Thorac Surg. 1993; 56: 1343-1347
        • Hoier-Madse K
        • Schulze S
        • Pederson VM
        • et al.
        Management of bronchopleural fistula following pneumonectomy.
        Scand J Thorac Cardiovasc Surg. 1988; 18: 263-266
        • Pridun N
        • Redl H
        • Schlag G
        Ein neues biologishches Implantat zum Verschluβ bronchopleuraler Fisteln.
        Z Herz Thorax Gefaβchir. 1987; 1: 60-62
        • Miyazaki Y
        • Sakashita H
        • Tanaka T
        • et al.
        Bronchopleural fistula successfully treated with surgical sponge.
        J Bronchol. 2001; 8: 282-285
        • Watanabe Y
        • Matsuo K
        • Tamaoki A
        • et al.
        Bronchial occlusion with endobronchial Watanabe spigot.
        J Bronchol. 2003; 10: 264-267
        • Albes JM
        • Schafers HJ
        • Gebel M
        • et al.
        Tracheal stenting for malignant tracheoesophageal fistula.
        Ann Thorac Surg. 1994; 57: 1263-1266
        • Witt C
        • Ortner R
        • Ewert R
        • et al.
        Multiple fistulas and tracheobronchial stenosis require extensive stenting of the central airways and esophagus in squamous-cell carcinoma.
        Endoscopy. 1996; 28: 381-385
        • Colt HG
        • Meric B
        • Dumon JF
        Double stents for carcinoma of the esophagus invading the tracheobronchial tree.
        Gastrointest Endosc. 1992; 38: 485-489
        • Freitag L
        • Tekolf E
        • Steveling H
        • et al.
        Management of malignant esophagotracheal fistulas with airway stenting and double stenting.
        Chest. 1996; 110: 1155-1160
        • Baumann MH
        • Strange C
        The clinician's perspective on pneumothorax management.
        Chest. 1997; 112: 822-828