Bronchopleural Fistula

Bronchopleural fistula (BPF) is a communication between the bronchial tree (main, lobar, segmental bronchus) and the pleural space, causing persistent air leak and empyema.

• Causes: post pneumonectomy or lobectomy bronchial stump dehiscence (1.5 to 4.5% after resection; right pneumonectomy higher), necrotising pneumonia, lung abscess, empyema, tuberculosis, radiation, chemotherapy, trauma, mechanical ventilation barotrauma, ruptured bulla or cyst, bronchial tumour.
• Risk factors for post resection BPF: right pneumonectomy, residual tumour at bronchial margin, long bronchial stump, preoperative radiotherapy, induction chemotherapy, steroids, diabetes, malnutrition, mechanical ventilation, infection.
• Timing: early (within 7 days; technical failure), intermediate (8 to 30 days), late (over 30 days; usually infection or recurrent tumour).
• Mortality 16 to 71% (especially post pneumonectomy with empyema).
• Complications: contralateral aspiration pneumonia, respiratory failure, sepsis, tension pneumothorax.

• Sudden dyspnoea, cough with expectoration of serosanguinous or purulent fluid (especially when lying on the healthy side), subcutaneous emphysema, fever, tachycardia.
• Persistent air leak in chest drain (bubbling throughout expiration or continuous), failure of lung re-expansion.
• Sudden fall in pleural fluid level on chest radiograph post pneumonectomy, tracheal shift to the contralateral side.
• Large leaks with ventilation: loss of delivered tidal volume.

• Chest radiograph: new air fluid level or drop of at least 2 cm in the post pneumonectomy space, new mediastinal shift, new pneumothorax.
• CT chest: direct visualisation of the fistula tract, abscess, residual cavity.
• Bronchoscopy (gold standard): identifies bronchial stump dehiscence, fistulous orifice; selective bronchial occlusion with balloon catheter and detection of air leak reduction, or instillation of methylene blue into the pleural space with detection in the bronchial tree.
• Pleural fluid culture; microbiology of sputum.
• Xenon-133 ventilation scan or quantitative assessment of leak in ventilated patients.

• Immediate: prevent aspiration (position with fistula side down), tube thoracostomy for drainage, avoid positive pressure ventilation where possible (use low pressures, high frequency ventilation, independent lung ventilation with double lumen tube), stop smoking, broad-spectrum antibiotics (piperacillin tazobactam 4.5 g every 6 hours, adding vancomycin).
• Empyema control: drainage, irrigation, open window thoracostomy (Clagett procedure: open drainage, followed by closure with muscle/omental flaps after sterilisation).
• Small fistulae (under 3 to 5 mm) in stable patients: endoscopic closure: tissue glue (cyanoacrylate, fibrin sealant), gelatin sponge, coils, endobronchial valves (one way valves), Amplatzer occluders, covered self expanding stents, polidocanol sclerosants; success 30 to 80%.
• Large fistulae (over 8 mm) or early post resection: surgical re-closure of bronchial stump with muscle flap (intercostal, serratus anterior, latissimus dorsi), omentoplasty, pericardial fat pad; completion pneumonectomy for lobectomy fistula; transsternal transpericardial approach for post pneumonectomy.
• Prolonged air leak with chest drain after lobectomy: observation (70% seal in 7 days), pleurodesis with autologous blood patch (50 to 100 mL), talc.
• Nutritional support (parenteral/enteral, protein 1.5 g/kg), glycaemic control, wean steroids.
• Treat underlying cause (tuberculosis therapy, tumour recurrence).
• Long term: follow up bronchoscopy and imaging; high risk of recurrence; prognosis is guarded.