[Post-lobectomy bronchopleural fistula -- a challenge for postoperative intensive care]

Progress Report on Interventional Treatment for Bronchopleural Fistula

Objectives

Bronchopleural fistula (BPF) is a serious and life-threatening complication. Following the advent of interventional radiology, subsequent treatment methods for BPF have gradually diversified. Therefore, this article provides an overview of the present scenario of interventional treatment and research advancements pertaining to BPF.

Methods

Relevant published studies on the interventional treatment of BPF were identified from the PubMed, Sci-Hub, Google Scholar, CNKI, VIP, and Wanfang databases. The included studies better reflect the current status of and progress in interventional treatments for BPF with representativeness, reliability, and timeliness. Studies with similar and repetitive conclusions were excluded.

Results

There are many different interventional treatments for BPF that can be applied in cases of BPF with different fistula diameters.

Conclusion

The application of interventional procedures for bronchopleural fistula has proven to be safe, efficacious, and minimally invasive. However, the establishment of comprehensive, standardized treatment guidelines necessitates further pertinent research to attain consensus within the medical community. The evolution of novel technologies, tools, techniques, and materials specifically tailored to the interventional management of bronchopleural fistula is anticipated to be the focal point of forthcoming investigations. These advancements present promising prospects for seamless translation into clinical practice and application, thereby potentially revolutionizing patient care in this field.

Bronchoscopic management of prolonged air leak

Bronchopleural fistula (BPF) with prolonged air leak (PAL) is most often, though not always, a sequela of lung resection. When this complication occurs post-operatively, it is associated with substantial morbidity and mortality. Surgical closure of the defect is considered the definitive approach to controlling the source of the leak, but many patients with this condition are suboptimal operative candidates. Therefore there has been active interest for decades in the development of effective endoscopic management options. Successful use of numerous bronchoscopic techniques has been reported in the literature largely in the form of retrospective series and, at best, small prospective trials. In general, these modalities fall into one of two broad categories: implantation of a device or administration of a chemical agent. Closure rates are high in published reports, but the studies are limited by their small size and multiple sources of bias. The endoscopic procedure currently undergoing the most systematic investigation is the placement of endobronchial valves. The aim of this review is to present a concise discussion on the subject of PAL and summarize the described bronchoscopic approaches to its management.

Treatment of Bronchopleural Fistula with Carbolic Acid instilled through Bronchofiberscope in post-pulmonectomy patients

OBJECTIVE

To investigate the efficacy of carbolic acid treatment of bronchopleural fistula (BPF) using bronchofiberscope (BFS) in post-pulmonectomy patients.

METHOD

Twelve patients with post-pulmonectomy BPF were enrolled in this study at the Liaoning Tumor Hospital between February 2009 and March 2012. Three patients had BPF after the right pneumonectomy, six patients after left pneumonectomy, one patient after the right middle and low lobectomy and two patients after left upper lobectomy. BPF patients were instilled with 100 % carbolic acid (0.5-1 ml one time every week) through BFS on the mucosal surface around the fistula, and the bubble disappearance was monitored. Treatment was repeated if the bubble remained.

RESULTS

No haemorrhage, severe dyspnea or SpO2 declines occurred in all the 12 patients during the bronchoscopic therapy. BPF orifices were closed in five patients after receiving 5 treatments with carbolic acid, 1 patient received 2 treatments, 1 patient was given 3 treatments, 2 patients received 4 treatments and 3 patients were given 7 treatments. Follow-up was conducted for six months following bronchoscopy. The average treatment and fistula closure time were calculated from the data collected as 20 min and 30 days, respectively, and the cure rate was 100 %. Hematoxylin-eosin (HE) staining results revealed that the white flat hyperplasia tissue after carbolic acid treatment was inflammatory granulation tissue.

CONCLUSION

Our results revealed that instillation of 100 % carbolic acid with BFS to treat BPF was 100 % effective, which can be a support for post-pulmonectomy BPF.

Retrograde Instillation of Methylene Blue in the Difficult Diagnosis of BPF

We report two cases in which we were able to diagnose bronchopleural fistula through retrograde methylene blue instillation during bronchoscopy. In the first case, methylene blue was injected through an abdominal drain, followed by air instillation and detected in the left bronchial tree, demonstrating the presence of a fistula in the lingula's bronchus. In the second case, methylene blue was injected into a pleural drain, through a breach on a surgical suture and detected in the right bronchial tree, demonstrating the presence of a fistula in the right inferior bronchus. The retrograde instillation of methylene blue, through a drain in the abdomen or the thoracic wall, is a safe, cheap, and practical method that allows the bronchoscopist to identify the presence of a fistula and, more importantly, to identify the exact point on the bronchial tree where a fistula is located. This provides the possibility of sealing the fistula with a variety of devices. It is our opinion that this procedure should be considered a primary method of diagnosis when a bronchopleural fistula is suspected and a drain on the thoracic or abdominal wall is positioned such that effusions are able to drain.

[Cleft in carbon dioxide absorber. Intraoperative problems with ventilation due to a leak in the breathing circuit]

In the case presented problems with mechanical and manual ventilation of a patient occurred during the operation. Prior to this endotracheal intubation had been performed without difficulty and the respirator had passed all system checks. A leakage in the recently changed carbon dioxide absorber could be detected which had been accidentally dropped and damaged internally.