Correct!
5. All of the above

A bronchopleural fistula is a leak between the proximal bronchi and the pleural space. They may happen after trauma or thoracentesis and often resolve spontaneously. When they do not resolve, they are often difficult to treat due to nature of the underlying disease that predisposes to their development (COPD, severe lung disease or trauma). To prove there is a bronchopleural fistula, the chest tube system must be carefully examined to ensure that there is no leak in the system, the tubing or at the entry site. Only when these are ruled out can a bronchopleural fistula be diagnosed. Treatment options have not been studied in a randomized fashion but the following are generally considered:

1. Watchful waiting since most will spontaneously resolve.
2. Reducing transpulmonary pressure gradients, i.e. lowering the pleural pressure gradient by avoiding positive pressure ventilation (NIV or intubation) and/or taking the tubes off negative pressure suction and leaving the tube on water seal
3. Pleurodesis either at bedside or by surgical VATS
4. Bronchoscopy to find the source and then attempting various glues/gels or intrabronchial valves.

After 3 weeks conservative measures had failed.  An Olympus intrabronchial one way valve system (IBV) was inserted.  IBVs are one way valves that allow air to leave the lung but not enter the lung (i.e., allow exhalation but not inhalation). Due to sedation issues, the patient was electively intubated for this. He was not hypoxic or in extremis at the time. The patient underwent bronchoscopic placement of several of these on the right side.

The post IVB valve placement CXR is shown in Figure 6.

Figure 6. Post intrabronchial valve insertion chest radiograph (Panel A) and its negative image (Panel B).

The patient was much more hypoxia after the procedure than before, and had to be placed on 100% oxygen and his PaO2 was only 60 mm Hg.

What is the most appropriate therapy at this time?

1. Increase positive end expiratory pressure
2. Place patient with his left side down
3. Place patient with his right side down
4. Begin extracorporeal membrane oxygenation (ECMO)
5. All of the above

Home/Critical Care