There are two types of communications that can develop between the lung parenchyma and the pleural space. Communications that develop in the peripheral lung, typically beyond the cartilaginous airways, are commonly referred to as peripheral air leaks. Peripheral communications generally demonstrate respiratory (phasic) variation in the magnitude of the air leak and will heal with time. In contrast, a communication with the cartilaginous airways is referred to as a bronchopleural fistula (BPF). BPFs are associated with a relatively larger communication. Negative-pressure external drainage usually demonstrates a continuous (nonphasic) air leak. Acute BPF, or communications with proximal airways, frequently require therapeutic intervention.
The etiology of acute BPF may be classified as infectious, malignant, traumatic, iatrogenic, and idiopathic (Table 130-1). The most common types of BPFs are associated with the complications of pulmonary resections. The surgical techniques for managing these problems are described in Chapter 82. The medical management of nonmalignant BPF is discussed in Chapter 127. This chapter summarizes the acute management options for benign BPF.
The acute surgical management of BPF depends not only on the etiology but also on the clinical presentation. In general, the main tenets of therapy are (1) the treatment of any systemic infection, (2) drainage of any infected fluid, (3) reexpansion of the lung to eliminate residual pleural space, and (4) treatment of the underlying cause. Specific management is discussed according to etiology.
The most common nonsurgical etiology for BPF is infection. BPF may be a complicating factor in necrotizing pneumonia or a lung abscess. A variety of bacterial, mycobacterial, and fungal infections have been implicated in benign BPF. Clues to the development of a lung abscess with proximal airway communication include an intractable cough, fever, weight loss, and failure to thrive.1 Clinical presentation may range from a productive cough to frank sepsis. A pneumothorax may be present as well; however, the presence of intrapleural air does not distinguish between a proximal and peripheral communication. Regardless of the site of communication, the initial management involves the drainage of the pleural space with a chest tube, broad-spectrum antibiotics to treat the underlying infection, and chest physiotherapy to aid drainage. Culture of the drainage fluid permits targeted antibiotic therapy. Surgical intervention is rarely indicated.
Malignant BPF is generally the result of the necrosis associated with large tumors in the chest. These may be primary lung carcinomas or metastatic cancers such as sarcomas. Patients may experience shortness of breath as a result of a pneumothorax. Management includes insertion of a chest tube to treat the pneumothorax and bronchoscopy to evaluate the proximal airways. Depending on the stage and location of the tumor, resection may be an option, but usually malignant BPF is associated with advanced disease.
Both penetrating and blunt chest trauma may result in a BPF. Laceration of the peripheral pulmonary parenchyma can be frequently managed by chest tube drainage alone. Failure to reexpand the lung after insertion of chest tubes, particularly in the presence of a continuous (nonphasic) air leak, is an indication for bronchoscopy and possible surgery. Injury to the proximal airway may necessitate thoracotomy with primary repair.
An air leak may be associated with radiation therapy, rupture of bullae, or positive-pressure ventilation. The accumulation of intrapleural air is an indication for insertion of a chest tube. A small leak that rapidly resolves does not require further intervention. A large or continuous air leak may require bronchoscopy to evaluate the proximal airways. In patients on mechanical ventilation for acute respiratory distress syndrome, a number of treatment options have been suggested, including jet ventilation and conventional ventilatory settings.2