Chapter 18

• Bronchopleural fistula is a direct communication between the bronchial tree and the pleural cavity causing an air leak from the lung. In pneumothorax, the communication is peripheral, between a ruptured bleb or alveolar duct and the pleural cavity.
• Anesthesia for patients with a BPF is based on two important techniques central to thoracic anesthesia: effective lung isolation and ventilation of an open airway.
• Prompt lung isolation is essential during anesthetic management in order to minimize the risk of ventilating the pleural cavity and soiling the contralateral lung.

A 72-year-old man with a history of T3N2 supraglottic squamous cell carcinoma, treated with chemoradiotherapy, was found to have a large tumor in the right lower lobe of the lung. Computed tomography (CT)–guided biopsy showed poorly differentiated squamous cell carcinoma. He underwent a right pneumonectomy with mediastinal lymph node dissection and a rotational serratus anterior muscle flap.

Following surgery, he remained intubated and ventilated overnight in the intensive care unit (ICU) and was extubated the following morning. On postoperative day 3 he developed refractory hypoxemia and respiratory failure requiring re-intubation and mechanical ventilation. The following week was characterized by deterioration in his clinical statewith low-grade fever, copious tracheal secretions, and persistent drainage of purulent pleural fluid from a chest tube. Serial chest radiographs and a CT scan revealed an increasing air level and decreasing pleural fluid level in the right pleural cavity, with consolidation of the left lower lobe. Fiber-optic bronchoscopy demonstrated purulent material trickling from a 3-mm-diameter bronchopleural fistula (BPF) in the bronchial stump.

A small open-window thoracostomy was created, and the pleural cavity was drained and thoroughly irrigated, and then packed daily. The patient received intravenous antibiotic therapy based on sensitivity analysis of blood and pleural fluid cultures; enteral feeding via a percutaneous gastrostomy tube; tight glucose control with insulin; and pressure control ventilation using permissive hypercapnea to maintain low mean airway pressures.

Over the next 4 weeks, the infection process was eradicated and the patient's clinical status improved. The BPF did not close spontaneously, however, as evidenced by a persistent air leak through the thoracostomy tube. This necessitated a return to the operating room for bronchoscopic assessment of the fistula, possible closure of the fistula with fibrin glue and, if needed, thoracotomy for BPF closure.

Bronchopleural fistula is a direct communication between the central bronchial tree and the pleural cavity which results from disruption of a bronchial stump or tracheobronchial anastomosis, causing an air leak from the lung. This contrasts with a pneumothorax, in which the communication is peripheral, between a ruptured bleb or alveolar duct and the pleural cavity. When the fistula or sinus tract of a BPF extends to the skin of the chest wall it is termed a bronchopleural-cutaneous fistula. Although rare, BPF represents a challenging management problem; it is associated with high rates of morbidity and mortality and poses formidable challenges during anesthetic ...

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