Management of bronchopleural fistula complicating therapy with positive end expiratory pressure (PEEP)

A return to 1992: Using the "blowhole" technique for diffuse subcutaneous emphysema caused by a broncho-pleural fistula

A bronchopleural fistula (BPF) is an abnormal communication between the bronchial tree and pleural space resulting in a high risk for morbidity and mortality. We describe a case highlighting the management of a BPF with subcutaneous and mediastinal air resulting in dysphagia and dysphonia using a technique that was first described in a 1992 CHEST article. The "Blowhole" technique may be utilized for patients that are poor surgical candidates requiring rapid correction and prevention of detrimental consequences such as pneumomediastinum, tension pneumothorax, upper airway compromise and pneumopericardium.

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.

Hemodynamic, ventilatory and gasometric evaluation of an experimental bronchopleural fistula

PURPOSE

To investigate the hemodynamic and ventilatory changes associated with the creation of an experimental bronchopleural fistula (BPF) treated by mechanical ventilation and thoracic drainage with or without a water seal.

METHODS

Six large white pigs weighing 25 kg each which, after general anesthesia, underwent endotracheal intubation (6mm), and mechanically ventilation. Through a left thoracotomy, a resection of the lingula was performed in order to create a BPF with an output exceeding 50% of the inspired volume. The chest cavity was closed and drained into the water sealed system for initial observation of the high output BPF.

RESULTS

Significant reduction in BPF output and PaCO2 was related after insertion of a water-sealed thoracic drain, p< 0.05.

CONCLUSION

Insertion of a water-sealed thoracic drain resulted in reduction in bronchopleural fistula output and better CO2 clearance without any drop in cardiac output or significant changes in mean arterial pressure.

Ventilator autocycling and delayed recognition of brain death

BACKGROUND

Improvements in technology play an important role in caring for critically ill patients. One example is the advance in ventilator design to facilitate triggering of mechanical breaths. Minimal changes in circuit flow unrelated to respiratory effort can trigger a ventilator breath and may mislead caregivers in recognizing brain death.

METHODS

We observed patients with devastating brain injuries in a mixed medical/surgical intensive care unit (ICU) with a high clinical suspicion for brain death including the absence of cranial nerve function with apparent spontaneous breathing during patient-triggered modes of mechanical ventilation. Further clinical observation for spontaneous respirations was assessed upon removal of ventilatory support.

RESULTS

Nine patients with brain injury due to multiple etiologies were identified and demonstrated no spontaneous respirations when formally assessed for apnea. Length of time between brain death and its recognition could not be determined.

CONCLUSION

When brain-dead patients who are suitable organ donors are mistakenly identified as having cerebral activity, the diagnosis of brain death is delayed. This delay impacts resource utilization, impedes recovery and function of organs for donation, and adversely affects donor families, potential recipients of organs, and patient donors who may have testing and treatment that cannot be beneficial. Patients with catastrophic brain injury and absent cranial nerve function should undergo immediate formal apnea testing.

Bronchopleural fistula: an update for intensivists

Bronchopleural fistula is a potentially fatal condition that may result after a variety of clinical conditions, most commonly after pulmonary resection. Either surgical or bronchoscopic repair is required to definitively correct these lesions, though a small number may resolve spontaneously with optimal ventilatory care and other options available to an intensivist in the management of this complex condition. The successful management of a bronchopleural fistula depends on formulating a treatment strategy tailored to individual patient needs.

Bronchopleural Fistulas

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.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.

Severe hyperventilation and respiratory alkalosis during pressure-support ventilation: report of a hazard

A 53-year-old woman with a flaccid quadriparesis developed severe hyperventilation and respiratory alkalosis during pressure-support ventilation. A gas leak in the ventilator system caused a loss of positive end-expiratory pressure and autocycling of the ventilator. Large ventilator breaths were then delivered because a high level of pressure support was set in a patient with low respiratory impedance. The complication is rare and its occurrence requires a combination of patient and equipment factors. Awareness of the responsible factors will promote detection and prevention of the hazard.

Ventilator autocycling due to an endotracheal tube cuff leak

Ventilator autocycling can occur with any ventilator if the sensitivity is improperly set or if a gas leak exists in the respiratory system which creates a negative change in proximal airway pressure. We report a case of ventilator autocycling in a paralyzed patient secondary to an endotracheal cuff leak which was misconstrued as assisted ventilation. We believe this is the first report of autocycling due to a cuff leak.

Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient

Bronchopleural fistulas are associated with high morbidity and mortality and are particularly challenging in the ventilated patient. Familiarity with both basic and more technical medical management techniques may lessen morbidity and improve survival. Prompt recognition of BPFs and appropriate placement of a chest tube with an adequate suction device are crucial to prevent potential tension pneumothorax and to drain an infected pleural space. The chest tube may be used therapeutically to decrease BPF air leak and to promote fistula repair. Appropriate conventional ventilator manipulations aimed at decreasing fistula air leak and maintaining adequate oxygenation and ventilation may fail and necessitate a trial of HFV. Definitive therapy by the bronchoscopic application of a sealing agent to occlude the fistula site can be used, particularly in the poor surgical candidate.

The relationship between peak inspiratory pressure and positive end expiratory pressure on the volume of air lost through a bronchopleural fistula

A bronchopleural fistula (BPF) may complicate the management of patients with major pulmonary disease or thoracic surgery. Neonates with idiopathic respiratory distress syndrome and requiring ventilation are especially susceptible to pulmonary barotrauma, which may result in a BPF. Morbidity and mortality are consistently high. In ventilating patients with BPF, the effects of peak inspiratory pressure (PIP) and positive and expiratory pressure (PEEP) on air leak have not been documented. These relationships were studied in rabbits prepared by thoracotomy and creation of a standardized BPF. Randomized trials of various levels of PIP and PEEP were applied, and the percent of inspired tidal volume lost through the BPF calculated. The percent of inspired volume lost does not increase significantly from 10 to 30 cm H2O PIP (p greater than 0.05). Percent leak does increase significantly when increasing PEEP frm 0 to 16 cm H2O (p less than 0.001). Any PEEP greater than 6 cm H2O results in more air loss through the BPF than any level of PIP (p less than 0.01). Linear regressions through a common origin were calculated to illustrate the relationship of PIP versus leak and PEEP versus leak. The slopes of these lines (0.572 and 3.97, respectively) are significantly different (p less than 0.001). When using equal increments of PIP and PEEP, PEEP will have over a sixfold greater effect on air leak than doses PIP. These data suggests that PIP should be increased preferentially when ventilating patients with BPF in order to minimize air leak. PEEP less than 6 cm H2O can be used without any significant increase in the volume of air lost.

Endobronchial control of bronchopleural fistulae

This report describes a proposed solution to the problem of high-flow bronchopleural fistulae in the adult respiratory distress syndrome. Animal studies and clinical application demonstrate the efficacy of this treatment.

Retroperitoneal air dissection associated with mechanical ventilation

The radiologic patterns, etiology, and possible consequences of gas dissection into the retroperitoneal space from pulmonary sources are reviewed in three patients requiring mechanical ventilation. Airway disruption appears to be related to peak airway pressures, underlying pulmonary disease, and the patient's hemodynamic condition and may cause different forms of interstitial emphysema and air embolization, which may lead to severe respiratory or circulatory dysfunction. Gas migration to the retroperitoneum and, secondarily, into the peritoneal cavity should be considered in the differential diagnosis of free intra-abdominal gas.

Treatment of bronchopleural fistula during continuous positive pressure ventilation

Pneumothorax as a complication of continuous positive pressure ventilation may result in the formation of bronchopleural fistula. If positive end-expiratory pressure cannot be sustained, the functional residual capacity and the ratio of alveolar ventilation to perfusion may decrease, and pulmonary gas exchange may be severely impaired. Recommended therapy includes removal of positive airway pressure and institution of negative intrapleural pressure via thoracostomy tube, but this may cause severe hypoxemia in patients with acute respiratory failure in spite of potentially toxic inspired oxygen concentrations. We applied positive intrapleural pressure equal to the end-expiratory airway pressure of three patients who developed bronchopleural fistula during therapy for acute respiratory failure. Positive intrapleural pressure facilitated resolution of the bronchopleural fistula in each case.