[Post-lobectomy bronchopleural fistula -- a challenge for postoperative intensive care]

Bronchopleural fistula (BPF) and bronchial stump insufficiency (BSI) after lobectomies and pneumonectomies are dreaded complications with incidences of up to 12 % and a mortality rate of up to 51 %. Apart from the basic illness causes include complications like aspiration-pneumonia and ARDS, formation of empyema as well as histories of sepsis. Corticoid treatments, old age, diabetes mellitus, previous irradiation as well as post-operative mechanical ventilation (barotrauma) are often counted among contributing causes. Suturing the bronchus and reinforcement by tissue are still the methods of choice, but they are often counter-indicated in high-risk patients. Endoscopic treatments with partial lung occlusions, e. g. by insertion of spongiosa, coils, and/or fibrin glue have been described. However, they require the respective area to be probable. With only one third the rate of success is quite unsatisfactory. The retro-graded instillation of inflammatory-selerotizing substances, like doxycycline, via a chest tube leads to a pleurodesis caused by adhesion of the remaining lung parenchyma to the thoracic wall and a reduction in size of the residual pleural space. In an 82-year old female patient a BPF of the second upper lobe bronchus was detected after a middle lobe resection for abscess and post-radiation ulcer following a mastectomy for carcinoma. The leakage was detected on bronchoscopy by retro-graded instillation via the chest tube of methylene-blue solution into the thoracic cavity. After administering the water-soluble contrast agent amidotrizoic acid in a similar manner a CT confirmed the diagnosis. As the bronchial segment concerned could not be entered selectively, preservation of the right lung lobe's residual ventilation by endoscopic-occlusion procedures was ruled out. Employing a strictly conservative therapy (spontaneous ventilation, retro-graded doxycycline instillations) complete healing with a fully ventilated lower lobe could be achieved over a period of 78 days. BPF as well as residual intro-thoracic cavities after lobectomies pose a serious problem. Using methylene blue for a retro-graded demonstration of BPF during bronchoscopy presents a feasible and cost-efficient diagnostic method. A strictly applied conservative therapy including short-time low-pressure artificial respiration as well as obliteration by fibrous tissue of the thoracic cavity using doxycycline is a feasible procedure for inoperable high-risk patients.