The clinician's perspective on pneumothorax management

OBJECTIVE

We sought to determine the current practice habits among clinicians treating spontaneous pneumothorax and bronchopleural fistula.

METHODS

Practice habits were determined by a randomized postal survey of 3,000 American College of Chest Physicians members. Group comparisons are performed by chi2 analysis with p<0.05 being significant.

RESULTS

Four hundred nine respondents (13.6%) included 176 practicing pulmonologists (43.0%), 67 academic pulmonologists (16.4%), 102 thoracic surgeons (25.0%), and 64 others (15.6%). More than 50% of respondents treat a first small primary spontaneous pneumothorax (PSP) by simple observation, a first small secondary spontaneous pneumothorax (SSP) by chest tube, persistent air leak in both PSP and SSP with chest tube+video-assisted thoracoscopy, and use a 20 to 24F chest tube in mechanically ventilated ARDS-related tension pneumothorax. First recurrences of PSP and SSP were treated by a variety of interventions that included simple observation (PSP=14%, SSP=4%), chest tube (22%/17%), chest tube+sclerosis (20%/16%), chest tube+video-assisted thoracoscopy (36%/48%), and chest tube+thoracotomy (5%/12%). The most popular sclerosing agents are doxycycline (48%), talc slurry (24%), and talc poudrage (19%). More than 75% of physicians intervened in a persistent air leak between 5 and 10 days. Chest tubes are initially placed to suction by 48% of respondents in PSP and removed >24 h after air leak ceases in 79%. Chest tube clamping prior to removal is employed by 67% of respondents. Significant differences exist between thoracic surgeons and pulmonologists with surgeons placing more chest tubes for first-time PSP and performing chest tube+video-assisted thoracoscopy for first recurrences of PSP more often than pulmonologists. Thoracic surgeons seldom use sclerosis in spontaneous pneumothorax compared to pulmonologists.

CONCLUSIONS

Marked practice variation exists in clinicians' approaches to the management of spontaneous pneumothorax and bronchopleural fistulas that is partially explained by differences between pulmonologists and thoracic surgeons. A national consensus statement is needed to guide randomized studies in pneumothorax management.

Closure of a bronchopleural fistula using decalcified human spongiosa and a fibrin sealant

Bronchopleural fistulas associated with empyema can occur as a life-threatening sequelae after pulmonary resection, most frequently occurring after pneumonectomy. With the use of the flexible bronchoscope, the bronchopleural fistula of a 62-year-old critically ill woman was permanently sealed with a fibrin sealant and a small section of demineralized human spongiosa. Closure of bronchopleural fistulas with the application of fibrin sealant plus human spongiosa may offer a valuable addition to the armament of therapeutic alternatives.

Management of bronchopleural fistula with a variable-resistance valve and a single ventilator

Independent lung ventilation with two ventilators is sometimes used in the management of bronchopleural fistula (BPF). We describe a patient in whom gas flow through a large BPF was initially reduced, and subsequently eliminated, during differential lung ventilation using a single ventilator and a variable-resistance valve attached to one lumen of a bifurcated endotracheal tube.

[Occlusion of an esophagobronchial fistula by implantation of a Montgomery esophageal and a dynamic tracheal stent after failure of conventional endoprosthesis]

Esophagorespiratory fistulas were frequently caused by malignant tumors, bougienage, laser therapy or radiochemotherapy. We here report the case of a patient with inoperable bronchial cancer, who developed a symptomatic esophagorespiratory fistula during combined radiochemotherapy with Cisplatin. A sufficient occlusion of the fistula could not be achieved with conventional plastic tubes or novel self-expanding silicone-coated Gianturco Song stents. After extraction of two Gianturco Song stents we inserted a Montgomery Salivary Bypass Stent into the esophagus and Dynamic stent into the trachea. This resulted in a total occlusion of the fistula. This present case suggests that the Montgomery stent may have little tendency to migrate due to its characteristic configuration and fixation and further demonstrates that the novel self-expanding silicone-coated Gianturco Song stents can be removed, if necessary.

Silicone-covered Wallstent prototypes for palliation of malignant esophageal obstruction and digestive-respiratory fistulas

BACKGROUND

Endoscopic palliation of malignant esophageal obstruction with uncovered self-expanding metal stents has been shown to have fewer complications than with conventional plastic stents. The addition of a membrane might prevent tumor ingrowth and allow treatment of digestive-respiratory fistulas. We report the clinical experience with a prototype silicone membrane-covered self-expanding metal stent.

METHODS

Twenty-three silicone membrane-covered Wallstent prototypes were used in 21 patients with dysphagia due to inoperable malignant tumors involving the esophagus and cardia.

RESULTS

Stent implantation was technically successful in all patients. There were no procedure-related perforations or deaths. The prototype stent was successful in sealing seven of the eight (87.5%) digestive-respiratory fistulas. As a group, the mean dysphagia grade improved significantly after stent placement (4.8 +/- 0.9 vs 3.4 +/- 1.6, p < 0.0005). However, 9 of 21 (42.9%) patients experienced no improvement in their dysphagia. Complications occurred in 13 of 21 (61.9%) patients. Tumor ingrowth was not observed in any patient.

CONCLUSIONS

The prototype covered self-expanding metal stent was effective in sealing digestive-respiratory fistulas and provided palliation of dysphagia in slightly more than one half of the patients studied. A great deal has been learned from the preliminary experience, which has led to design modifications. The utility of the commercially available device should be evaluated in further prospective clinical trials.

[Fibrin-glue in the treatment of a bronchocutaneous fistula]

The treatment of postoperative chronic thoracic fistulas with fibrin glue can be the non-operative ideal solution for the relative simplicity of the execution technique.

[A case of malignant esophageal stenosis with esophagobronchial fistula treated with a covered wallstent]

A polyurethane-covered Wallstent was used for a esophagus cancer patient with malignant esophageal stenosis associated with esophagobronchial fistula. Stent placement was successfully performed with no procedure related-complications. Following the procedure the patient could eat a normal diet. The insertion of a polyurethane-covered Wallstent is a safe and effective treatment for malignant esophageal stenosis with esophagobronchial fistula.

Treatment of a ruptured anastomotic esophageal stricture following bougienage with a Dacron-covered nitinol stent

A patient suffering from esophagorespiratory fistula after bougienage of a benign stricture at the site of the anastomosis between a jejunal interposition and the esophagus was referred for interventional treatment. A prototype nitinol stent centrally covered with Dacron was implanted under regional anesthesia and fluoroscopic guidance. The self-expanding prosthesis dilated the stenosis completely and closed the fistula, with consequent improvement in respiratory and nutritional status and thus the general quality of life. The patient was able to eat and drink normally until death 3 months later due to progression of his underlying malignant disease.

Management of malignant esophagorespiratory fistula

For patients with malignant esophagorespiratory fistula, four important points need to be stressed: (1) once the diagnosis is made, treatment should be instituted immediately; (2) all treatment is palliative and directed at stopping soilage of the respiratory tract; (3) the type of therapy is dictated by the performance status of the patient at presentation; and (4) esophageal bypass offers the best palliation for those able to tolerate the procedure.

Independent lung ventilation

Situations in which independent lung ventilation may be of use include massive hemoptysis, pulmonary alveolar proteinosis, risk of interbronchial aspiration, unilateral lung injury, single lung transplant, and BPF. Any decision to attempt independent lung ventilation should take into consideration the many technical difficulties associated with the procedure. They include difficulties in the placement of DLTs and monitoring tube position, the risk of tube displacement, and the risk of airway trauma. The clinician also must consider the costs in terms of available manpower and resources. Maintaining a patient on independent lung ventilation requires highly skilled nursing care, specialized monitoring devices, and readily available FOB. Even with these limitations, independent lung ventilation may be of use in certain clinical situations when standard methods have failed.

Broncho-mediastinal fistula following perforation of the oesophagus

We present a 63-year old female with mediastinitis following an esophageal perforation, possibly favoured by an oesophageal motility-disorder and the use of non-steroidal anti-inflammatory drugs, who developed a broncho-mediastinal fistula in the left main bronchus. She was successfully treated with intravenous antibiotics, a cervical oesophagostomy and secondary isoperistaltic coloplasty.

Management of late postpneumonectomy empyema and bronchopleural fistula

Postpneumonectomy empyema occurs in 5% of pneumonectomy patients, more commonly with completion pneumonectomy, right pneumonectomy, operations for sepsis, mediastinal lymph node dissections, and in patients requiring postoperative mechanical ventilation. BPF is identified in over 80% of patients at presentation. Optimal management includes prevention by minimizing perioperative sepsis, meticulous bronchial closure, and the use of vascularized flaps to reinforce the bronchial stump. Management of the developed complication requires flexible bronchoscopy, drainage of the empyema space initially by closed tube drainage, and later by open thoracostomy, appropriate therapy of the underlying infection, and identification and correction of systemic risk factors. Surgical interventions to obliterate the residual empyema space are successful in 80% of cases. Closure of BPF occurs spontaneously in one third of cases, but can be achieved in 86% of cases with aggressive surgical interventions involving reclosure of the bronchial stump and transposition of vascularized flaps. The mortality of postpneumonectomy empyema, with or without BPF, ranges from 23% to 50%. The mortality for surgical intervention is 10%. In the absence of debilitating systemic illness, such as metastatic lung cancer, aggressive surgical intervention is the optimal method of management for postpneumonectomy empyema with an associated bronchopleural fistula.

Management of postpneumonectomy empyema and bronchopleural fistula

Postpneumonectomy empyema with or without fistula is a serious complication. Management includes drainage, antibiotherapy, debridement closure of the bronchopleural fistula when present, and obliteration of the residual pleural space. Excellent results can be obtained in most patients using the Clagett procedure and its modification. A detailed description of each step of the surgical treatment of postpneumonectomy empyema and associated bronchopleural fistula is provided.

Fibrin sealant in thoracic surgery. Pulmonary applications, including management of bronchopleural fistula

This article characterizes the pulmonary surgical applications of fibrin sealant. It discusses the current uses of fibrin sealant in pulmonary operations; summarizes the available methods of fibrin sealant production; reviews the commercial availability of fibrin sealant compounds; and elaborates on future developments for fibrin sealant in the United States.

Esophagorespiratory fistulae due to esophageal carcinoma: palliation with a covered Gianturco stent

PURPOSE

To evaluate therapeutic effects and complications of a covered Gianturco stent for esophagorespiratory fistulae.

MATERIALS AND METHODS

Of 95 patients with esophageal carcinomas, 10 had esophagorespiratory fistulae and were treated with a silicone-covered Gianturco stent. The authors retrospectively assessed patients' food intake capacity and delayed problem of the stent.

RESULTS

All fistulae were occluded without immediate complications. Two patients could swallow all foods; four, most foods; three soft foods; and one, only liquids. Clinical problems occurred between 1 and 24 weeks in four patients: reopened fistula (n = 1), recurrent fistula (n = 1) (both patients were successfully treated with another esophageal stent), and dyspnea (n = 2) due to tracheal compression by stent and tracheal invasion by tumor (one patient was treated with a tracheal stent).

CONCLUSION

A silicone-covered modified Gianturco stent is effective for palliation of esophagorespiratory fistulae caused by esophageal cancer. Simultaneous use of a tracheal stent is recommended for extrinsic tracheal narrowing by the proximal tip of the stent and invasion by tumor.

Closure of a benign broncho-oesophageal fistula by endoscopic injection of bovine collagen, cyanoacrylate glue and gelfoam

Endoscopic application of adhesives and occlusives has been used to treat both benign and malignant tracheo-oesophageal fistulae. Successful management of a large benign broncho-oesophageal fistula by endoscopic reduction of the opening with injected bovine collagen and occlusion of the lumen with gelfoam and cyanoacrylate plugs reported.

Endoscopic treatment of bronchobiliary fistula: report on 11 cases

BACKGROUND/AIMS

There are reports of treatment of biliary cutaneous fistulae by endoscopically placed nasobiliary drains. We report our fistulae treatment results from this method.

MATERIALS AND METHODS

We treated 11 patients with bronchobiliary fistulas (BBFs) endoscopically during the last 6 years. In most cases, the BBF's were the result of Hydatid cyst operations. Six patients had simultaneous biliocutaneous fistula (BCF).

RESULTS

All BBFs and BCFs closed after the nasobiliary drain placement without any complication. Three patients who developed fistula recurrence healed with endoscopic treatment.

CONCLUSION

Endoscopic treatment is a viable alternative to surgical treatment.