Persistent bronchopleural fistula in a patient with adult respiratory distress syndrome. Treatment with pressure-controlled ventilation

Bronchopleural fistula (BPF) continues to present a treatment problem in mechanically ventilated patients. We report a patient with a traumatic BPF, pneumonia, and adult respiratory distress syndrome (ARDS) who was successfully ventilated with pressure-controlled ventilation (PCV). This mode, by allowing the use of lower inspiratory airway pressures, may promote closure of the fistula.

Management of bronchopleural fistula in the adult respiratory distress syndrome

Bronchopleural fistula occurring as a complication in patients with the adult respiratory distress syndrome typically appears after 1 to 2 wks of illness, and is associated with a poor prognosis. Whether the bronchopleural fistula per se worsens outcome is not known because of the lack of studies on its natural history. There are several potential adverse effects of bronchopleural fistula in adult respiratory distress syndrome (e.g., incomplete lung expansion, loss of effective tidal volume or positive end-expiratory pressure, inability to remove CO2, etc.), but the actual frequency of these problems among patients with this complication appears to be low, and their magnitude and clinical impact remain uncertain. Most of the literature consists of anecdotal reports of innovative measures for reducing the leak, such as manipulation of chest tube suction, high-frequency jet ventilation, independent lung ventilation, and various maneuvers using the fiberoptic bronchoscope. Controlled studies are lacking, however, and the application of sound, general management principles is of primary importance. The great majority of patients can be managed satisfactorily without resort to unfamiliar, labor-intensive, potentially hazardous measures.

Palliative endoscopic treatment of malignant esophagorespiratory fistula: case report

The authors report on a case of esophagorespiratory fistula due to squamous carcinoma of the esophagus treated on an emergency basis by endoscopic insertion of an Atkinson prosthesis following dilation of the malignant stenosis with Savary dilators. The authors suggest the endoscopic insertion of a prosthesis as the first approach in the emergency treatment of a malignant esophagorespiratory fistula because of the easiness of the technique, and its low morbidity and mortality rates; furthermore, this procedure relieves digestive and respiratory symptoms rapidly and reduces hospital stay while providing the patient with a better quality of remaining life.

Optimal application of high-frequency ventilation in infants: a theoretical study

A recent multicenter study of preterm infants concluded that high-frequency ventilation (HFV) applied at 15 Hz, in comparison with conventional mechanical ventilation (CMV), did not lead to reduced incidence of barotrauma, contrary to previous expectations. The primary goal of the present theoretical study was to determine whether computed estimates of lung pressures during HFV and CMV are consistent with these findings. An existing theoretical model of lung mechanics and gas transport in HFV was modified for applicability to neonates. New features, such as expiratory flow limitation and pulmonary air leak, were also incorporated. Simulations with the model were conducted assuming combinations of frequency and tidal volume that maintained a constant level of eucapnia. We found that peak alveolar pressures and the magnitude of alveolar pressure swings resulting from HFV at 15 Hz were in general comparable to those produced by CMV in healthy neonates and infants with bronchopulmonary dysplasia; peak alveolar pressures in the latter group tended to be higher with HFV than in CMV. Application of HFV at 15 Hz was even less advantageous than CMV when pulmonary air leak was also present in the infants with bronchopulmonary dysplasia. However, the model predicted the existence of an optimal range of frequencies between 2 and 4 Hz in which alveolar pressure swings and peak alveolar pressures could be minimized, and in some cases, reduced below the levels produced by CMV.

Esophagorespiratory fistula associated with esophageal cancer: treatment with a Gianturco stent tube

A self-expanding silicone-covered tube constructed of Gianturco stents was used for palliative treatment of esophagorespiratory fistula related to esophageal carcinoma in eight patients. All eight were unable to swallow food or water before treatment. The tubes were inserted under fluoroscopic guidance, without technical failure or complication. Clinical improvement was determined by grading food intake capacity on a five-point scale: none, liquid, soft food, most food, or all food. After the procedure, all fistulas were occluded. Four patients could swallow most foods, two could swallow soft food, one could swallow all foods, and one (who died of preexisting pneumonia 10 days after the procedure) could manage only liquids. Three patients were surviving without symptoms of aspiration for 4-24 weeks. Four patients died 6-16 weeks after placement of the stent tubes. Insertion of a silicone-covered stent tube was an effective palliative treatment for esophagorespiratory fistulas caused by esophageal cancer.

Pneumatoceles and pneumothoraces complicating staphylococcal pneumonia: treatment by synchronous independent lung ventilation

A 54 year old man with a staphylococcal sepsis developed staphylococcal pneumonia complicated by multiple pneumatoceles and bilateral tension pneumothoraces caused by bronchopleural fistulae. Excessive enlargement of the right sided pneumatoceles and a tension pneumothorax not improved by drainage led to mediastinal shift and compression of the right lung. Reversal of the mediastinal shift and closure of the bronchopleural fistulae was achieved by assisted independent lung ventilation.

[Methods for the curative treatment of pleural empyema with bronchial fistulae in patients with pulmonary tuberculosis]

In contrast to non-specific pleural empyemas in which closed sanitization is sufficiently beneficial, an early application of thoracostoma is essential for patients with tuberculous pleural empyema with bronchial fistulas. Thoracostoma allows for effective sanitization of the cavity, long-term antituberculous chemotherapy and preparation of patients for radical operations. This has been supported by the comparative analysis of the outcomes of radical operations in 139 patients following closed and open management of the empyemic cavity in pulmonary tuberculosis. The site of thoracostoma is defined depending on the location and volume of an abscess and the forthcoming radical operation. Long-acting antiseptic dressings containing chlorohexidine bigluconate, which are based on the polymer polyhydroxyethyl methacrylate and which have been developed in the clinical setting, and ultraviolet irradiation with a unique-design apparatus are proposed for sanitization of open pleural empyemas.

[Bronchopleural fistula in a newborn: report of one case]

Persistent pneumothorax is infrequently seen in the neonate. Persistent pneumothorax with a large air leak and empyema may indicate the presence of a bronchopleural fistula which often results in mortality in infants requiring ventilator support. A ten-day-old female neonate with meconium aspiration syndrome was found to have respiratory distress after birth. During ventilator therapy, persistent pneumothorax with a large air leak from the chest tube was found. Empyema occurred three days later. Despite insertion of multiple chest tubes and use of bronchial balloon occlusion, a large air leak and empyema still were noted. Following thoracotomy and suture of the bronchopleural fistula, the air leak stopped. The patient was smoothly weaned from the ventilator. She was able to be discharged in good condition six weeks later. In management of the bronchopleural fistula, bronchial balloon occlusion enabled the patient to be maintained until more specific therapy could be attempted. Thoracotomy is definite therapy for selected infants requiring ventilator support who demonstrate a large air leak, persistent pneumothorax, and progressive hypoxia which is unresponsive to chest tube insertion.

[Instrumental methods in the treatment of non-specific spontaneous pneumothorax]

The results of treatment of 226 patients with unspecific spontaneous pneumothorax in 1980-1990 are discussed. Poor efficacy of punctures of the pleural cavity (32.4%) is noted. Pleural cavity drainage proved to be effective in 79.7% of cases, both in primary and in recurrent pneumothorax. Chemical pleurodesis with tetracycline and 4% sodium bicarbonate solution was conducted in patients with complicated forms of pneumothorax (bronchopleural fistulas, hydropneumothorax). The advantage of 4% sodium bicarbonate solution over the tetracycline solution was obvious. To prevent the development of encapsulated hydrothorax the authors improved the method of pleural cavity drainage. The described method of instrumental treatment of spontaneous pneumothorax allowed injurious surgical intervention and recurrent pneumothorax to be avoided in 100% of cases.

[Endoscopic closure of the postoperative bronchopleural fistula]

A case of successful endoscopic closure of a bronchopleural fistula with fibrin glue was reported. Fifty-eight-year-old man underwent right lower lobectomy for lung carcinoma. On the 21st postoperative day, he suffered from high fever and diagnosed as right side pyothorax. Then tube thoracotomy was done under UCG-guide. As a fistula in the right lower bronchial stump was found tiny by BFS, we tried to close the fistula bronchoscopically with fibrin glue. The fibrin glue was injected into the fistula via the ERCP tube, which was passed through the bronchoscope. This procedure was performed twice for two weeks interval. The fistula was completely closed about a month after the trial. This method is useful to close postoperative small bronchopleural fistula without surgical intervention.

Endobronchial closure of a postpneumonectomy bronchopleural fistula

Successful permanent endobronchial closure of a serious postpneumonectomy bronchopleural fistula is reported in a patient with a delayed diagnosis of Mycobacterium fortuitum-cheloni infection. Increasing experience, improved plugging agents, and a review of the literature suggest that in selected patients, this procedure can avoid complex repeat operations and reverse life-threatening situations. Although atypical mycobacterial infections occur with infrequency, they are difficult to treat and may lead, as in this patient, to a misdiagnosis. Operations on granulomatous tissues are prone to heal poorly, thus inviting tissue breakdown and chronic fistulas.

Lobar bronchial blockade in bronchopleural fistula

A 59-yr-old man with bullous lung disease developed a refractory bronchopleural fistula involving the right upper lobe. Despite independent lung and high-frequency jet ventilation, a large air leak persisted. Following the introduction of a bronchial blocker into the right upper lobe bronchus via the tracheal lumen of a left-sided endobronchial tube, oxygenation and ventilation improved, and the airleak was reduced by 90%. The presence of pneumonia led to an inexorably downhill course with death from overwhelming sepsis.

Endoscopic management of large, postresection bronchopleural fistulae with methacrylate adhesive (Super Glue)

Bronchopleural fistulae that occur following pulmonary resection are usually managed by direct, operative closure. In complex cases, in which the risk of repeat thoracotomy is great, other means may be preferable. We report two patients, one with cystic fibrosis and one with extensive radiation fibrosis post-Askin's tumor, in whom the risk of thoracotomy was considered to be prohibitive. Both had a large fistula between the pleural cavity and a segmental bronchus from the right upper lobe. The cystic fibrosis patient had recurrent massive bleeding from the pleural space. A Teflon catheter was passed through a flexible bronchoscope and Super Glue (butyl or methyl methacrylate) was deposited into the fistula. In both cases, the fistula resolved promptly. One patient developed a large, recurrent granuloma at the site of the fistula requiring endoscopic resection. We believe that tissue adhesive may be a reasonable approach to the management of large bronchopleural fistulas when the risk of operative closure is great.

Successful use of autologous fibrin gel in traumatic bronchopleural fistula: case report

Bronchopleural fistula has been successfully treated by bronchoscopic application of fibrin glue. We report the use of intrathoracic fibrin gel pleurodesis in traumatic bronchopleural fistula.

Postoperative pyothorax

Twenty-five cases of pyothorax occurred in a series of 1281 thoracotomies. Almost all cases of pyothorax without bronchopleural fistula were successfully treated by closed drainage and irrigation alone. On the other hand, patients with pyothorax and fistula who were treated only with closed drainage almost all had a poor outcome. When pyothorax with fistula was treated by closed drainage and irrigation followed by further procedures such as open window thoracostomy, muscle plombage and/or omentopexy, treatment was successful. It is concluded that pyothorax without fistula may be cured by closed drainage and irrigation alone, but that pyothorax with fistula requires operative intervention such as open window thoracostomy or omental flap as soon as possible.

Malignant esophagorespiratory fistula: management options and survival

The development of a malignant esophagorespiratory fistula is a devastating complication. Data comparing various treatment options in a large group of patients are sparse. To assess the results of therapy, we reviewed our experience in 207 patients with malignant esophagorespiratory fistula. Records of 207 patients admitted to our institution with malignant esophagorespiratory fistula from 1926 to 1988 were reviewed and results of management analyzed. Age ranged from 21 to 90 years (median, 59 years); the male/female ratio was 3:1. Primary tumor site was esophagus in 161 (77%), lung in 33 (16%), trachea in 5 (2%), metastatic nodes in 4 (2%), larynx in 3 (1%), and thyroid in 1. Symptoms and signs of malignant esophagorespiratory fistula included cough in 116 (56%), aspiration in 77 (37%), fever in 52 (25%), dysphagia in 39 (19%), pneumonia in 11 (5%), hemoptysis in 10 (5%), and chest pain in 10 (5%). Respiratory location of fistula included trachea in 110 (53%), left main bronchus in 46 (22%), right bronchus in 33 (16%), lung parenchyma in 13 (6%), and multiple sites in 5 (2%). The percentage of patients alive at 3, 6, and 12 months by treatment modality was 13%, 4%, and 1% for supportive care (n = 104); 17%, 3%, and 0% for esophageal exclusion (n = 29); 21%, 14%, and 0% for esophageal intubation (n = 14); 30%, 15%, and 5% for radiation therapy (n = 20); and 46%, 20%, and 7% for esophageal bypass, respectively. Patients treated with radiation therapy and esophageal bypass had a significantly prolonged survival compared with patients treated with the other modalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Esophageal intubation for malignant fistulas

Between April 1978 and December 1989 at the Endoscopy Division of the National Cancer Institute of Milan, 140 patients were intubated for esophageal neoplasms; 19 of these subjects underwent endoscopic intubation for malignant fistulas complicated by pneumonia and/or mediastinitis. The prostheses were tolerated well and enabled the restoration of oral nutrition. The mean survival was 4.7 months (range, 0.5-17 months). No major complications occurred. Tube dislodgement was observed in 2 cases (10.5%). Two patients died of causes that were not related to the procedure.

Duodenobronchial fistula

Duodenobronchial fistulas are an extremely rare subgroup of abdominobronchial fistulas, which include bronchobiliary, gastrobronchial, enterobronchial, colobronchial, and splenobronchial fistulas. Only one case of a duodenobronchial fistula has been previously reported. Duodenobronchial fistulas occur as a complication of a duodenal injury. The characteristic symptoms are a cough that produces copious bilious secretions, shortness of breath, and fever. The diagnosis is made by contrast gastrointestinal studies. Treatment requires an abdominal approach with interruption of the fistula at its duodenal origin and control of the inciting inflammatory process. With prompt diagnosis and treatment, thoracic drainage or pulmonary resection should not be needed.