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BRONCHOPLEURAL FISTULA (BPF)

Coordinator Moderators

: Dr. Sugandha : Dr. Geetha N K :Dr. Rajeev D S : Dr. Frank Amal

Presenter

DEFINITON
A persistent abnormal communication between tracheobrochial tree and pleural cavity Cutaneous BPF additional communication to the surface

CAUSES OF BPF
Breakdown of suture/staple line following lung resection
More common following right pneumonectomies Manual Vs stapled bronchial closure.

Rupture of cavity
Bulla Cyst Abscess Bleb

CAUSES OF BPF
Erosion of bronchial wall
Empyema Pneumonia TB. Neoplasm Foreign body

CAUSES OF BPF
Penetrating trauma Iatrogenic
Barotrauma Thoracocentesis Tracheobronchial biopsy Traumatic intubation

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY
Disruption involves the the tracheobronchial tree. The disruption occurs when a 1-way valve forms, allowing air inflow into the pleural space and prohibiting air outflow. The volume of this non absorbable intrapleural air increases with each inspiration because of the 1-way valve effect. As a result, pressure rises within the affected hemi thorax. As the pressure increases, the ipsilateral lung collapses and causes hypoxia.

In ventilated patients, suspect bronchopleural fistula when increased pleural pressures causes
An increase in peak airway pressure in order to deliver the same tidal volume. Decreased expiratory volumes secondary to air leakage into the pleural space and Increased end-expiratory pressure, even after discontinuation of PEEP PFT - T.V , FRC, R.V, FEV1,

PATIENT IN THE LATERAL DECUBITUS POSITION WHEN AWAKE AND WHEN ANESTHETIZED

ANAESTHETISED, OPEN CHEST, LATERAL DECUBITUS POSITION

The nondependent lung is well ventilated but poorly perfused The dependent lung is poorly ventilated but well perfused .

Opening the chest


nondep lung compliance larger part of TV goes to the nondependent lung

Paralysis Larger part of TV goes to


the nondependent lung because P of the abd contents pressing against the upper part of the diaphragm is minimal. So easier for IPPV to displace this lesser resisting dome of the diaphragm.

V/Q MISMATCH & LATERAL POSITION

Awake
V ND D Q

Anaesthetised
V Q V Q

Early findings
Chest pain Dysponea Anxiety Tachyponea Tachycardia Hyper resonance of the chest wall on the affected side Diminished breath sounds on the affected side

Late findings
Decreased level of consciousness Tracheal deviation toward the contralateral side Hypotension Distension of neck veins (may not be present if hypotension is severe) Cyanosis

Further pressure build-up causes the mediastinum to shift toward the contra lateral side and impinge on both the contra lateral lung and the vasculature entering the right atrium of the heart. This condition leads to worsening hypoxia and compromised venous return. The inferior vena cava is the first to kink and restrict blood flow back to the heart. evident in trauma patients who may be hypovolemic with reduced venous blood return to the heart.

Hypoxia leads to increased pulmonary vascular resistance via vasoconstriction. Decreasing cardiac output and worsening metabolic acidosis secondary to decreased oxygen delivery to the periphery occur, thus inducing anaerobic metabolism. If the underlying problem remains untreated, the hypoxemia, metabolic acidosis, and decreased cardiac output lead to cardiac arrest and death. Infection of contralateral lung

Types
Central : 2/3rd due breakdown of pneumonectomy /lobectomy) Peripheral :1/3rd due to breakdown of distal staple line

Incidence :
4.5 %-20% following pnemonectomy 0.5% following lobectomy

PREDISPOSING FACTORS
Technical difficulty with bronchial closure Residual tumor Pre Op Irradiation Diabetes Infection Long bronchial stump Complete pneumonectomy

CLINICAL FEATURES & MGT


Presentation & treatment of post-surgical BPF depend on
Size of the air leak
Small -<3mm Large>10mm( 20 -50% of tidal volume)

Type of resection Time of presentation


Early (1st several days of Surgery Delayed (weeks to years) e.g. empyeme

CLINICAL FEATURES OF POST PNEUMONECTOMY BPF


Acute dehiscence present as
Sudden large in air leak Various degrees of respiratory distress Mediastinal shift Low grade fever and cough resp. distress & hypoxemia CXR sudden drop in air-fluid level

Bronchogram shows escape of dye through bronchopleural fistula into chest tube

DIAGNOSIS
Clinical Injection of methylene blue into pleural space recovery from sputum Chest X-ray Broncoscopy, Bronchography

INVESTIGATION
Complete Blood Count RBS CT scan :chest identify empyema cavity and guide location of chest tube placement Bronchoscopy :location and closure by balloon the BPF

RESUSCITATION
Position :sitting and supported, pneumonectomised side down Oxygen by face mask I.V access for saline ,antibiotics and dysarrthymias Chest drain to remove fluid prevent risk of infection on the opposite lung Mechanical ventilation if large fistula Isolate with single or double lumen tube Surgical closure

POST PNEUMONECTOMY BPF


Delayed BPF management
Early thoracotomy Antibiotics Respiratory support Debridement & dressing change Packing the cavity with antibiotic soaked material Correction of dehydration & malnutrition Usually heals within 4 to 6 Wks Otherwise surgical closure

MANAGEMENT

CHEST TUBE MANAGEMENT IN BPF


AIM Drain pleural space Re-expansion of remaining lung Suctioning

COMPLICATION
High mortality due
Sepsis Respiratory failure Malnutrition Erosion of pulmonary artery stump

BROCNOPLEURAL FISTULA ANESTHETIC CONSIDERATION

ANAETHESIOLOGIST NEEDED
Diagnostic Bronchoscopy Establishment of closed or open drain system Repair of acute stump dehiscence Debridement Fistula closure with muscle flap obliteration Decortications Lung isolation Optimal ventilation in mechanically ventilated patient in ICU

ANESTHETIC CONSIDERATION
Pre op evaluation most essential Purely on clinical grounds Poor general condition Large BPF loss of tidal vol. V/Q mismatch hypoxia & hypercarbia Infection, malnutrition, dehydration Respiratory distress & circulatory collapse ( tension pneumothorax) Hazards of emergency surgery full stomach

ANESTHETIC CONSIDERATION
SPECIFIC RISK PPV large air leak insufficient ventilation & oxygenation enlargement of fistula contamination of contra lateral lung Hence ,Maintain spontaneous ventilation till affected side is isolated

ANESTHETIC CONSIDERATION
Goals 1. Minimization of airflow through the fistula 2. Adequate gas-exchange in unaffected lung 3. Avoid hypoxemia at any cost 4. Avoid positive pressure ventilation until fistula isolated 5. Avoidance of tension pneumothorax 6. Protection against contamination of remaining lung

ANESTHETIC CONSIDERATION
Improve general condition Oxygen I/V fluid Antibiotics Circulatory support Chest tube drainage FOB

ANESTHETIC CONSIDERATION
Pre op investigation In addition to routine 1. CXR 2. PFT 3. ABG 4. Bronchoscopy 5. Evaluation of loss of tidal volume
1. Intermittent or continuous air bubbles through chest tube 2. Measuring expired tidal volume

BRONCHOSCOPY
Topical anaesthesia
Head end elevated Ultra short acting narcotics and topical anaesthesia

IV induction with short acting agents with single lumen ETT and Bronchoscopy during aponea period If hypoxia occurs ,advance over bronchoscope ETT into unaffected lung bronchus, saturation improves ,tube pulled back for FOB EXAMINATION

Establish lung isolation DLT. FOB through Tracheal Lumen Inhalation induction maintaining Spontaneous Ventilation
Disadvantage coughing ,cross contamination

TIVA with spontaneous ventilationmargin of safety between inadequate and excess depth

INDUCTION, INTUBATION, ISOLATION


Patient sitting up with affected side dependent PPV should be withheld until fistula is isolated Suction on chest tube should be discontinued to loss of tidal volume

INDUCTION, INTUBATION, ISOLATION

AWAKE INTUBATION
Theoretically attractive
Spontaneous ventilation until Ability to cough IPPV

Practically difficult
Sick hypoxic patient unable to cooperate Cough when LA. spray applied Penetration of mucosa by LA impaired

GENERAL ANESTHESIA WITH SPONTANEOUS VENTILATION


Advantage
1. More patient comfort 2. Less incidence of coughing

Disadvantage
1. Altered kinetics of inhalational agent due to fistula 2. Hypotension with inhalational agents 3. Spontaneous Ventilation may fail before depth is sufficient without coughing

RAPID SEQUENCE INDUCTION


Atraumatic intubation with no coughing Safe only if the tube can be sited correctly & reliably at first attempt Disadvantage
Experienced anaesthiologist and staff needed Endobronchial blockers are useless

CHOICE OF ISOLATION
Double lumen tube-tip cannot be controlled after the tip enters the larynx
 Lumen on fistula side should be occluded before giving positive pressure ventilation to prevent pressure building up within  In failure to Intubate consider Endotracheal Intubation.

Single lumen Endobronchial tube-placed under direct vision


 If fistula is small and uninfected standard ETT can be used  Gentle manual ventilation  Drain chest  Apply pressure to drain for adequate gas exchange with each positive pressure ventilation

Disadvantage:
Risk of surgical emphysema Risk of adhesion Drain cannot be guaranteed

Bronchial blockers DLT most commonly used

TECHNIQUE
Premedication small dose of anxiolytics and anticholinergics ( inj. Atropine)
Disadvantage
Patient has already tachycardia Interfering with mucocilary clearance

Advantage
Decreases bronchial secretion and saliva

Transportation to O T
Patient sitting with pneumonectomised side dependent Drain clamped and disconnected Re establish free drain in O T before induction Oxygen by mask

IN THE O.T
Patency of drain is checked Reassure the patient Oxygen supplementation Check suction apparatus ,Endobronchial equipment and emergency drugs

MONITORS
ECG Pulse Oximeter NIBP PNS End Tidal CO2 Temperature probe Oesophageal sthescope CVP

TECHNIQUE
Position :Patient induced and intubated in sitting position and anesthesiologist stands on a stool behind the head Preoxygenation Sleep dose of thiopentone and a fully paralyzing dose of suxamethonium Endobronchial Intubation is inserted without prior inflation of the lung

Bronchial cuff is secured Patient is ventilated with oxygen Then lowered to supine position Endobronchial and pharyngeal toilet completed Patient turned to lateral position, chest re explored Bleeding is unusual if excessive contamination At the end of surgery test integrity of airway pressurizing & and looking for air bubble in a saline filled hemi thorax

TECHNIQUE
Reestablish spontaneous ventilation at the end if at all possible IPPV with low peak inflation pressure if spont. not possible HFPPV is preferred to conventional mechanical ventilation

VENTILATORY MANAGEMENT
Provide ventilation only to one lung Allowing the fistula to heal Not possible in patients with associated pulmonary pathology due to large shunt Unilateral PEEP may also the shunt

VENTILATORY MANAGEMENT
Differential lung ventilation DLT with independent volume settings for each lung by 2 synchronized ventilators Normal lung ventilate normally Diseased TV & PEEP kept reduced Level of CPAP just below critical opening pressure of fistula

HIGH FREQUENCY JET VENTILATION


ADVANTAGE
Minimal loss of TV Fistula heal more quickly Airway resistance, pulm. Compliance will have minimal influences Low airway pressure Spontaneous efforts are abolished less sedation & no need of paralysis

VENTILATORY MANAGEMENT
MONITORING 1. Measuring continuously volume of gas passing from the chest tube by inserting a flow tube sensor 2. Other less reliable methods
 Assessing amount of air bubble  Difference between inspired and expired tidal volume

LUNG CYST

LUNG CYST
A thin walled air filled cavity with in the lung which is large enough to be seen on a plain xray. Cysts and bullae can be considered together Classified as congenital & acquired

LUNG CYST
Congenital
Bronchogenic cyst Congenital cystic adenomatiod malformation Cong. Lobar emphysema

Acquired
Bullous emphysema Hydatid cyst Traumatic lung cyst

LUNG CYST
Hazards in pathophysiology
Small cyst rarely cause symptoms

Cyst become problematic if


They become enlarged & cause mass effect (tension cyst) If they rupture & create a pneumothorax If they become infected

Hydatid cyst ,pulmonary sequestration and CCAM are usually uninfected, without bronchial communication ,small, asymptomatic

LUNG CYST
Infected cyst
Communicating more prone for recurrent infection Fever, cough, purulent sputum, occasional hemoptysis

Tension cyst
Communicating cyst can trap by ball valve mechanism causes rapid expansion, pneumothorax & mass effect Acute cardio - respiratory instability

LUNG CYST
Emphysematous bullae
Formed due to destructive process of emphysema Air can be trapped with in bullae because of preferential inflation & elastic recoil Expiratory obstruction of emphysema contribute to expansion Ball valve mechanism causes sudden rapid expansion

LUNG CYST
Pathophysiology
Space occupying lesion impaired expansion of lung elastic recoil of lung parenchyma airway resistance Distortion of bronchial anatomy further increase airway obstruction Flattened diaphragm and hyper expanded rib cage disadvantage for mechanics of respiration Can be a source of dead space and WOB

HYPOTENSION
Decreased venous return due to increased intrathoracic pressure Extrinsic restriction of diastolic ventricular filling (tamponade effect) Mediastinal shift Treatment
Restore venous return by fluids , vasopressor and reduce the volume of cyst by surgical decompression or lung isolation (DLT)

Patho physiology

The major types of pneumothorax are:


Open pneumothorax Closed pneumothorax Spontaneous pneumothorax -<40yrs. Pulmonary barotrauma -mechanically ventilated

Air can enter the mediastinum (the space in the center of the chest between the lungs), especially during an asthmatic attack, When a lung biopsy specimen is taken at the time of Bronchoscopy Thoracentesis (removal of fluid from the pleural space), the pleura lining the lung may be penetrated,

CT scan through the lower lobes, lung window display, shows a thin-walled cyst in the left lower lobe (arrow).

Insertion of chest drain

Underwater chest drain


The site is between the 4th and 7th intercostal spaces, between the mid-axillary and anterior axillary lines. Aseptic technique, infiltrate skin and subcutaneous tissues with local anaesthetic. Incise chest wall 2 cm below proposed site of insertion. Perform blunt dissection using artery forceps through to the pleural cavity.

Using the tip of finger, sweep adherent lung away from the insertion site. Insert the drain into the pleural cavity and slide into position (usually towards the apex). Connect the drain to an underwater seal device. Perform a purse-string suture around the puncture site to aid sealing after removal. Some chest drains come with a flexible trocar, thus avoiding risk of trauma.

The underwater seal device


The effective drainage of air, blood or fluids from the pleural space requires an airtight system to maintain sub atmospheric intrapleural pressure. This allows re-expansion of the lung and restores Hemodynamic stability by minimizing mediastinal shift. The basic requirements are a suitable chest drain with minimal resistance, an underwater seal and a collection chamber.

ICD

The drainage tube is submerged to a depth of 1-2 cm in a collection chamber of approximately 20 cm diameter. This ensures minimum resistance to drainage of air and maintains the underwater seal even in the face of a large inspiratory effort. The chamber should be 100 cm below the chest as sub atmospheric pressures up to -80 cmH2O may be produced during obstructed inspiration. Drainage can be allowed to occur under gravity, or suction may be applied.

The underwater seal acts as a one-way valve through which air is expelled from the pleural space and prevented from reentering during the next inspiration Retrograde flow of fluid may occur if the collection chamber is raised above the level of the patient Absence of oscillations may indicate obstruction of the drainage system by clots or kinks, loss of sub-atmospheric pressure or complete re-expansion of the lung Persistent bubbling indicates a continuing bronchopleural air leak The collection chamber should be kept below the level of the patient at all times to prevent fluid being siphoned into the pleural space. Clamping a pleural drain in the presence of a continuing air leak may result in a tension pneumothorax

Pre-operative assessment Pre-operative preparation

ANESTHETIC CONSIDERATION
Infected cyst usually communicate with tracheo bronchial tree & pose a risk of contamination Secure lung isolation rapidly Drainage with antibiotics should precede surgery

ANESTHETIC CONSIDERATION
Large cyst
Large cyst can never be ignored whether it is in a symptomless or breathless patient They compress adjacent lung Likely to enlarge when N2O is used Enlargement resp. distress, rupture, pneumothorax

ANESTHETIC CONSIDERATION
May be inflated preferentially during mechanical ventilation inefficient gas exchange Rapid enlargement if communication is valvular Cyst may rupture in closed chest and cause pneumothorax

ANAESTHETIC CONSIDERATION
Local anaesthesia is a suitable option GA is given avoiding nitrous oxide Avoid mechanical ventilation or IPPV but spontaneous respiration is maintained In mech. Ventilation minimize peak inflation pressure Facilities for prompt drainage should be ready Endobronchial intubation avoided during emergency surgery

Gradual enlargement of cyst usually missed Ruture of cyst is followed by respiratory distress bronchospasm ,marked resistance to inflation and mediastinal shift Presence surgical drapes makes auscultation difficult ICD inserted and attached to under water seal without suctioning, it does not interfere with adequate ventilation

THORACOTOMY
Surgery indicated if it interfere with PFT Usually Plication Or Obliteration Of Cyst Done Spontaneous ventilation and nitrous oxide avoided until chest is opened DLT for single or both lung ventilation
For generalized emphysema

Single lumen if trachea distorted and if isolated lung cyst and opposite lung is healthy ETT Intubation gentle positive pressure ventilation by hand Period of risk-induction to opening of chest and surgeon in control of the cyst

ANESTHETIC CONSIDERATION
IN BILATERAL LESIONS The compromised lung should be operated Expanding cyst / pneumothorax may develop in non operative lung, this will produce hypoxemia, hypotension during OLV

LUNG ABSCESS
Fluid filled cavity unlikely to increase in size Liable to rupture during manipulation DLT to isolate the lobe containing the cyst COMPLETE PROTECTION TO OPPOSITE LUNG AND ROUTE FOR SUCTION Endobronchial blocker

TREATMENT
Antibiotics If it rupture :postural drainage Complication
BPF as long as infection persist

HYDATID CYST
Mostly in sheep rearing countries Pathophysiology Enlarge and form daughter cyst or
Rptures Calcify Secondary cyst Anaphylactic reaction

Difficult to treat Removal without spillage Lobectomy if infected or large cyst Small cyst enucleated Aspiration and 10% formalin to kill scolices

Formalin socked swabs used during operation Cryoprobes Silver nitrates 0.5% DLT if cyst rutures Median sternotomy or b/l thoracotomy for cyst involving both lungs Post analgesia

ANESTHETIC CONSIDERATION
Post operative leaks are major source of morbidity Effective reexpansion by recruitment maneuvers Prevented by
Minimizing ventilatory pressure and volume Tailoring the anesthetic technique for rapid return of spontaneous ventilation

Treatment
Patient is put on supine position If significant air leak
re-explored. post op ventilation with pressure controlled ventilation chest tube placed under water

REFERENCES
Miller:text book of anaesthesia Kaplan :thoracic anaesthesia Benumof:thoracic anaesthesia

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