The presentation of a bronchopleural fistula developing acutely (within hours to days) after surgery is fairly dramatic. It is heralded as the sudden onset of dyspnea, subcutaneous emphysema, cough w/ purulent sputum, or a life-threatening tension pneumothorax. Thoracic surgery patients invariably have a chest tube in the immediate postoperative period to avoid or immediately identify this complication. A continuous airleak or increase in the output of air in the waterseal chamber of a pleural fluid collection container should alert the physician to the possibility of a bronchopleural fistula. Bronchopleural fistulas identified within the first 4 days postoperative should return for re-exploration and closure of the stump leak if clinical situation allows.

The subacute (postoperative day 7–30) or chronic presentation (postoperative day >30) for a bronchopleural fistula is less impressive. Patients complain of fatigue, wasting, dyspnea, low-grade fevers, or productive cough. Hemoptysis or metalloptysis (coughing of surgical material) has been described. After pneumonectomy, there is an expected degree of and air and fluid present for at least a few weeks. The space is usually obliterated within 7 months. A major decrease in pleural effusion or dramatic change in the air–fluid pattern (increasing pneumothorax, changes in hydropneumothorax level, new air–fluid level) after pulmonary resection should raise concern for a postoperative BPF. Depending on type of surgery and loculation(s) in the pleural space, subtle changes may not be readily visualized on a plain chest radiograph. In the chronic setting, bronchopleural fistulas typically occur as a result of chronic pleural space infection or fibrosis, usually in an immunocompromised patient. Reappearance of air in a previous obliterated space is an ominous sign for BPF. Overall, bronchopleural fistulas are most commonly diagnosed between 8 and 12 days postoperative.

The presentation of a BPF in the non-postoperative patient depends on the characteristics of the underlying disease. Most patients will have fever, persistent cough, thick and/or copious sputum production, and a pleural effusion with an air–fluid level. A patient with existing pneumonia or empyema, however, may already be exhibiting these symptoms leading to a delay in diagnosis. A non-resolving pneumonia, infiltrate, or effusion, especially in a patient with underlying lung disease, should warrant further investigation. In patients on mechanical ventilation, an abrupt and significant decrease in airway pressures should raise concerns for BPF formation. Hemoptysis may occur in malignancy-related fistulas, and cough and SOB during eating can be seen with esophageal to airway fistulas.

In general, there is a high morbidity and mortality associated with bronchopleural fistulas. Mortality generally falls in the range of 20–70%, depending on the underlying disease process. Postoperative fistulas which can be surgically repaired have a lower morbidity and mortality than fistulas related to underlying malignancy or infection. Even with successful intervention, mortality still can be as high as 40%. Death is usually related to a combination of aspiration and recurrent infections (pneumonia, empyema) which may lead to the development of acute respiratory distress syndrome and multiorgan system failure.

The initial management of any BPF should first address any immediate, life-threatening conditions, such as pleural space contamination, pulmonary flooding, or tension pneumothorax. A chest tube, if not already in place, should be inserted immediately to address these concerns. In complex cases with pleural adhesions and/or loculated hydropneumothoracies, multiple well-positioned and/or image-guided chest tubes may be required. In the case of BPF due to a necrotizing lung or pleural space infection, a trial of antibiotics with adequate drainage should be attempted to decompress the pleural space, allowing time for full lung re-expansion and healing of the fistula. With severe necrotizing pneumonia, many weeks of antibiotic therapy, nutritional supplementation, patient rehabilitation, and chronic pleural space drainage may be required before contemplating surgery. Although it is tempting to surgically close a fistula, active infection in the lung parenchyma or pleural space can lead to worse outcomes in the acute setting.

Bronchopleural fistulas are very difficult to manage while the patient is on mechanical ventilation. Ventilator-delivered breaths will preferentially flow through the fistula as it represents the lowest point of resistance in the airway. This leads to difficulties with oxygenation and loss of exhaled tidal volumes and subsequent hypercapnia. Limiting airway pressure is an important strategy as continued airflow through the tract delays natural healing. Minimization of positive end expiratory pressure (PEEP), inspiratory flow rate, and tidal volume should be attempted to the extent tolerated by the patient. In large fistulas, selective intubation of the contralateral lung may be necessary to completely cease any airflow through the fistula. High frequency oscillatory ventilation has been studied and found to be slightly more beneficial in patients with a proximal BPF and lack of parenchymal disease.

After initial drainage of the pneumothorax, the chest tube may actually contribute to the persistence of the BPF. In patients with minimal or no residual pneumothorax, suction should be removed and the chest tube placed on waterseal. Keeping the chest tube on suction may have a paradoxical effect by “pulling” the defect open and contributing to the persistence of the BPF. Withdrawal of suction from the chest tubes minimizes airflow through the fistula to allow improved healing of the tract. Installation of a pleural sclerosing agent (talc, bleomycin, etc.) through the chest tube into the pleural space is often attempted as a minimally invasive method for sealing an airleak. The goal is to fuse (pleurodese) the visceral and parietal pleura together, which will either contain the airleak or incite an inflammatory response to close the fistula. In order for this to be successful, the lung needs to completely fill the hemithorax so that there is good apposition between the visceral and parietal pleural surfaces. If a large pneumothorax is present, pleurodesis will not be achieved and the airleak will persist.

Conservative measures (as described above) for closure of a bronchopleural fistula are necessary in patients who are poor surgical candidates or have small peripheral defects which do not necessitate more aggressive intervention. In cases where conservative treatment fails, localization of the fistula is paramount in successful closure of the fistula either by semi-invasive (bronchoscopic) or invasive (surgical) management. There have been no large studies describing the optimal treatment or outcomes for bronchopleural fistulas nor does consensus opinion exist to suggest an optimal treatment in any particular situation. Regardless of the cause of the fistula, endoscopic and surgical treatment should not be viewed in isolation; instead, they can be complementary techniques.

If a postoperative BPF is detected within a few days of the patient’s original surgery, re-exploration by either VATS or open thoracotomy with closure of the fistula is the recommended approach if the clinical situation allows. The success rate of BPF closure with surgery has been reported to be as high as 80–95%, although this includes the postoperative population that is healthy enough to undergo a major reoperation. There are multiple surgical options described for closure of a BPF: (1) VATS/thoracotomy with direct resection and closure of the stump with intercostal muscle reinforcement or omental flap, (2) trans-sternal bronchial closure, (3) thoracoplasty with or without extrathoracic chest wall muscle transposition, or (4) chronic drainage with chest tube or Eloesser procedure (described below). Sequential operative procedures are often planned in debilitated patients who would not tolerate another major operation. Bronchopleural fistula complicated by empyema is one such circumstance where sequential operations may achieve better success. The pleural cavity is allowed to continuously drain by an empyema tube or an Eloesser procedure. The Eloesser procedure was named after Leo Eloesser, the thoracic surgeon who first described the technique. It involves the creation of a 5-cm opening in the chest wall with resection of 2–3 adjacent ribs and suturing of the skin to the pleural cavity to allow complete continuous drainage of the pleural space. The Eloesser procedure has minimal morbidity even in chronically ill patients and can be used in the acute setting. The patient then undergoes aggressive nutritional support and intensive physical rehabilitation and returns to the operating room once healthy enough to tolerate a second procedure for a thoracotomy with flap closure of the BPF. The details and technical aspects of surgical closure of bronchopleural fistulas are beyond the scope of this discussion. (Please refer to suggested reading at the end of this chapter for additional resources.)