A simple technique for managing a bronchopleural fistula while maintaining positive pressure ventilation

Area of Science:

• Critical Care Medicine
• Pulmonary Medicine
• Thoracic Surgery

Background:

• Positive pressure ventilation can lead to bronchopleural fistula (BPF), a serious complication.
• High levels of positive end-expiratory pressure (PEEP) may exacerbate BPF.
• Managing BPF during mechanical ventilation presents significant clinical challenges.

Observation:

• A case of BPF developed in a patient receiving controlled ventilation with PEEP of 22 cm H2O.
• The BPF resulted in continuous fistula flow, consuming 75% of tidal volume.
• Oxygenation deteriorated significantly, with aAO2 dropping from 0.27 to 0.14.

Findings:

• Conventional treatments for BPF were ineffective in this case.
• A custom bedside system was developed to apply positive pressure to the pleural space ipsilateral to the BPF.
• This intervention reduced fistula leak by decreasing the expiratory transpulmonary pressure difference, stabilizing PEEP and oxygenation.

Implications:

• The described system offers a readily constructible, adjustable method for managing large BPFs at the bedside.
• This approach allows for the maintenance of positive pressure ventilation with PEEP while managing BPF flow.
• This technique may improve outcomes for patients with severe BPF complicating mechanical ventilation.