Step 1
Surgical Anatomy
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Bronchopleural fistulae are more common after a right pneumonectomy than after a left pneumonectomy because the right main bronchus extends into the pleural space, whereas the aortic arch and the mediastinal tissues cover the left main bronchus ( Fig. 18-1 ).
Figure 18-1
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A falling air-fluid level is usually diagnostic of fistula. A fall of more than 1.5 ribs is significant and should raise the suspicion of a bronchopleural fistula ( Figs. 18-2 and 18-3 ).
Figure 18-2
Figure 18-3
Step 2
Preoperative Considerations
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It is important to protect the remaining lung by placing the patient with the operative side down so the infected fluid does not drain via the bronchus into the remaining lung.
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Antibiotics should be started and the fluid drained out of the space using a chest tube if the fluid has not already been coughed out by the patient.
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Nutritional status is an important consideration in this group of patients. Often they are debilitated from the chronic infection. Nutritional supplements should be considered in all patients.
Step 3
Operative Steps
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Operative repair is usually necessary and requires careful airway management. A double-lumen tube or a single-lumen tube with a bronchial blocker can be used to protect the remaining lung when the patient is placed in the lateral decubitus position ( Fig. 18-4 ).
Figure 18-4
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The prior thoracotomy is reopened, and the infected material is débrided. Once the chest cavity is clean, the bronchial stump is identified (pressurizing the airway with saline in the cavity will cause bubbles to come from the hole in the airway and facilitate identifying the stump) and its edges dissected ( Fig. 18-5 ).
