Management of a bronchopleural fistula using differential lung airway pressure release ventilation

Bronchopleural Fistula in the Mechanically Ventilated Patient: A Concise Review

OBJECTIVE

To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of positive-pressure ventilation. To provide guidance of lung isolation, mechanical ventilator, pleural catheter, and endobronchial strategies for the management of bronchopleural fistula on mechanical ventilation.

DATA SOURCES

Online search of PubMed and manual review of articles (laboratory and patient studies) was performed.

STUDY SELECTION

Articles relevant to bronchopleural fistula, mechanical ventilation in patients with bronchopleural fistula, independent lung ventilation, high-flow ventilatory modes, physiology of persistent air leak, extracorporeal membrane oxygenation, fluid dynamics of bronchopleural fistula airflow, and intrapleural catheter management were selected. Randomized trials, observational studies, case reports, and physiologic studies were included.

DATA EXTRACTION

Data from selected studies were qualitatively evaluated for this review. We included data illustrating the physiology of driving pressure across a bronchopleural fistula as well as data, largely from case reports, demonstrating management and outcomes with various ventilator modes, intrapleural catheter techniques, endoscopic placement of occlusion and valve devices, and extracorporeal membrane oxygenation. Themes related to managing persistent air leak with mechanical ventilation were reviewed and extracted.

DATA SYNTHESIS

In case reports that demonstrate different approaches to managing patients with bronchopleural fistula requiring mechanical ventilation, common themes emerge. Strategies aimed at decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure decreases airflow across the bronchopleural fistula.

CONCLUSIONS

Mechanical ventilation and intrapleural catheter management must be individualized and aimed at reducing air leak. Clinicians should emphasize reducing peak inspiratory pressures, reducing positive end-expiratory pressure, and limiting negative intrapleural pressure. In refractory cases, clinicians can consider lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in appropriate patients as well as definitive management with advanced bronchoscopic placement of valves or occlusion devices.

Retained drains causing a bronchoperitoneal fistula: a case report

Abstract

Conclusion

To the best of our knowledge, this is the first known case report of a bronchoperitoneal fistula caused by retained surgical drains. This is also the first known report that details successful management of this condition with advanced ventilatory techniques. This case highlights the importance of follow-up for trauma patients since retained surgical drains have the potential to cause life-threatening complications. When faced with this condition, clinicians should be aware of advanced ventilatory methods that can be employed in the intensive care unit. In this case, these techniques proved to be life-saving.

Differential lung ventilation during adult donor care

Differential lung ventilation may be required when one lung is injured or affected more than the other lung following, for example, aspiration, crush injury, or selective pneumonia, or if lung rupture results in formation of a bronchopleural fistula. Unilateral lung failure causes increased ventilation-perfusion mismatching that often leads to severe hypoxemia. Treatment may include careful attention to ventilator parameters to avoid overdistention of the less-affected lung or lateral decubitus positioning of the donor with the less-affected lung down (gravitationally dependent position). Under extreme conditions, use of a specialized double-lumen endotracheal tube and separate ventilators with individualized parameters for each lung is required to provide adequate oxygenation and ventilation for organ preservation.

Differential Lung Ventilation during Adult Donor Care

Differential lung ventilation may be required when one lung is injured or affected more than the other lung following, for example, aspiration, crush injury, or selective pneumonia, or if lung rupture results in formation of a bronchopleural fistula. Unilateral lung failure causes increased ventilation-perfusion mismatching that often leads to severe hypoxemia. Treatment may include careful attention to ventilator parameters to avoid overdistention of the less-affected lung or lateral decubitus positioning of the donor with the less-affected lung down (gravitationally dependent position). Under extreme conditions, use of a specialized double-lumen endotracheal tube and separate ventilators with individualized parameters for each lung is required to provide adequate oxygenation and ventilation for organ preservation.