Bronchopleural fistula

A bronchopleural fistula is a connection between the airways and the pleural space. Bronchopleural fistulas cause pneumothorax in penetrating chest injury, after thoracic surgery, and in spontaneous pneumothorax as well as in most cases of iatrogenic pneumothorax (e.g. needlestick etc.). If a bronchopleural fistula persists during positive-pressure ventilation, tension pneumothorax develops in almost all cases. Drainage of a pneumothorax with a persistent bronchopleural fistula results in an air leak which can be detected by the continuous bubbling of air through the water seal of the suction system. A persisting bronchopleural fistula usually seals spontaneously within a few days. The incidence of persisting bronchopleural fistulas is higher during positive-pressure ventilation and in chronic obstructive pulmonary disease patients with intrinsic PEEP. Therapeutic measures to decrease the causative increased back-pressure increase the likelihood of sealing the air leak. However, this is a dilemma, particularly in mechanically ventilated acute respiratory distress syndrome patients who need a higher airway pressure to maintain oxygenation. Large bronchopleural fistulas occur particularly after thoracic trauma due to severe direct airway injury and during acute respiratory distress syndrome because of the inflamed fragile lung tissue and the application of high airway pressure. Major airway injury such as tracheal or main-stem rupture must be treated surgically, but lung surgery to seal large air leaks in acute respiratory distress syndrome is difficult and problematic because of the tissue fragility.

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