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

The development of a bronchopleural fistula (BPF) is an infrequent, but potentially devastating complication of positive pressure ventilation. A case report is detailed in which a BPF arose in a patient on controlled ventilation with a PEEP of 22 cm H2O. Within 12 hours, fistula flow was continuous and accounted for 75% of the delivered tidal volume. PEEP fell rapidly during expiration; oxygenation steadily deteriorated as the aAO2 fell 0.27 to 0.14. Conventional treatment methods were unsuccessful, and a system was constructed for adding controlled levels of positive pressure ot the pleural space on the side of the BPF. By decreasing the expiratory transpulmonary pressure difference (PEEP minus pleural pressure), the fistula leak was greatly decreased, and PEEP and oxygenation were stabilized. This system can be rapidly constructed at the bedside with equipment routinely available in most hospitals and offers the ability to adjust the expiratory transpulmonary pressure, lung volume, and BPF flow while maintaining positive pressure ventilation with PEEP.