Treatment of bronchopleural fistula during continuous positive pressure ventilation

Pneumothorax as a complication of continuous positive pressure ventilation may result in the formation of bronchopleural fistula. If positive end-expiratory pressure cannot be sustained, the functional residual capacity and the ratio of alveolar ventilation to perfusion may decrease, and pulmonary gas exchange may be severely impaired. Recommended therapy includes removal of positive airway pressure and institution of negative intrapleural pressure via thoracostomy tube, but this may cause severe hypoxemia in patients with acute respiratory failure in spite of potentially toxic inspired oxygen concentrations. We applied positive intrapleural pressure equal to the end-expiratory airway pressure of three patients who developed bronchopleural fistula during therapy for acute respiratory failure. Positive intrapleural pressure facilitated resolution of the bronchopleural fistula in each case.