bronchoscopy Bronchoscopy Fistula*

in the Management of Bronchopleural

MAJ john E. McManigle, M.D.; MAJ Gardner L. Fletcher, M.D.; and COL Michael F. Tenholder, M.D., F.C.C.P.

The management of persistent bronchopleural fistula is one of the most complex challenges encountered by the chest physician. Bronchopleural fistulae most commonly arise as a postoperative complication, but can occur in other clinical settings, such as inHammatory disease of the lung, blunt chest trauma, and barotrauma. 1-4 Necrotic lung and BPF are also increasingly being recognized as a sequela to current aggressive chemotherapy and radiation therapy for lung cancer. 5 The incidence of this disorder has decreased markedly with the availability of more effective chemotherapeutic agents for tuberculosis, improved antimicrobials, and advanced surgical technique. The current incidence of BPF following pulmonary resection is generally reported as 2 to 5 percent. One recent article reports a 12.5 percent incidence of BPF following pneumonectomy for nonsmall lung cancer. 6 Two large series from the 1970s report a mortality rate from this complication of 23.1 and 19.1 percent, respectively. 1•2 When BPF occurs, the healing and repair process is still associated with substantial morbidity and mortality, prolonged hospitalization, and great expense. Patients with BPF can present in an acute, lifethreatening fashion due to pulmonary Hooding or tension pneumothorax. These fistula can also have a subacute, insidious clinical course. The acute clinical presentation is recognized by the onset of sudden dyspnea, expectoration of purulent material, subcutaneous emphysema, and disappearance of Huid level on chest roentgenogram (if postoperative). A persistent air leak postoperatively, without evidence of a techni*From the Division of Pulmonary Disease, Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; and Pulmonary Disease and Critical Care Medicine, Department of Medicine, Walter Reed Army Medical Center, Washington, D.C. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army, Department of the Air Force, or Department of Defense. Reprint requests: Dr. McManigle, Rm A3060 Department of Medicine, USUHS, 4301 Jones Bridge Rood, Bethesda 20814-4799

cal problem in the pleural drainage apparatus, also indicates a BPF. When a fistula occurs outside the perioperative period (no chest tube in place), the diagnosis must be suspected in the face offever, cough productive of purulent sputum, and new or increasing air Huid level in the pleural space. Further diagnostic studies such as selective bronchography 1•3 •7 or instillation of methylene blue into the bronchial tree, with its subsequent appearance in the chest tube drainage, can help confirm the BPF location. The first principle of BPF management must be to address any immediate, life threatening conditionscommonly pulmonary Hooding or tension pneumothorax. This is accomplished by placing the patient with affected side down and performing a pleural drainage procedure. If a major bronchial stump dehiscence occurs during the first week after pulmonary resection, immediate resuture and reinforcement of the bronchial stump is the procedure of choice. 2 •3 •8 However, most BPF present subacutely or as a chronic air leak. These patients initially receive conservative management with dependent drainage and reduction of the pleural space, antimicrobials, optimal ventilator management,1H2 and nutritional supplementation. Ifthese conservative measures fail to close the fistula in one to three weeks, surgical intervention is usually considered the next step in management. Unfortunately, many of these patients are poor surgical candidates unable to tolerate a major thoracic procedure. Application of silver nitrate through the rigid bronchoscope has been used successfully to treat stump fistulae. 6 The advent of Hexible bronchoscopy has improved localization of smaller peripheral fistula. In cases with difficult localization or marked anesthesia risk, the bronchoscopist can now use several nonoperative techniques to attempt endobronchial closure of BPF. These modalities include endobronchial occlusion with (1) tissue glue, 13-17 (2) fibrin glue, 1"'22 (3) Gelfoam, 23 (4) lead plugs, 24 (5) balloon catheter,25 •26 or (6) autologous blood patch. 27 Ifsuccessful, these techniques eliminate the risk of general anesthesia and CHEST I 97 I 5 I MAY, 1990


FIGURE 1. Endobronchial view of a proximal bronchopleural fistula at a bronchial stump. The catheter through which tissue glue will be injected, can be seen adjacent to the fistula.

major reconstructive thoracic surgery. We will discuss these various techniques for use in selective patients when conservative management of BPF has been unsuccessful. TECHNIQUE

The first step in the evaluation of a BPF being considered for endoscopic closure is to determine whether the lesion might be amenable to bronchoscopic techniques. To do this, one must either directly visualize the BPF proximally or demonstrate that occlusion of a distal BPF significantly decreases or stops the air leak. If neither of these conditions is present, attempts at endobronchial control ofBPF will be futile and therefore should not be attempted. A proximal BPF, directly visible through the rigid or Oexible bronchoscope (Fig 1), is seen when a small fistula forms at the bronchial stump following lobectomy or pneumonectomy. We routinely record the exact anatomic location on videotape for review with our surgical colleagues. A peripheral BPF, not directly visible with a rigid endobronchial examination, presents a greater challenge both in identification and characterization of the fistula. These are commonly seen with inOammatory lung disease, blunt trauma, barotrauma, or following segmental or wedge resection in patients with underlying lung disease. To locate a peripheral BPF, the bronchoscopist systematically examines the segmental bronchi on the involved side. Air bubbles can sometimes be seen arising from the affected bronchus (but can also be seen arising from normal bronchi). Respiratory maneuvers (ie, cough) may accentuate the bubbling in the involved segment. 1238

Ifnot, washing the suspected area with normal saline solution can enhance localization of the air leak. The bronchoscopist then passes a balloon catheter (Microvasive occlusion catheter, No. 5 Fogarty embolectomy catheter, Swan-Ganz catheter, or other similar catheter) through the suction channel of the fiberoptic bronchoscope to sequentially occlude all suspicious lung segments. The catheter is advanced into second, third, or fourth order bronchi, and the occlusion balloon inflated while an assistant carefully observes the air leak. A marked reduction of the air leak will accompany successful occlusion of the BPF. Ifsignificant reduction of the air leak cannot be demonstrated during balloon occlusion of distal BPF, endoscopic closure should not be attempted. It must be emphasized that the catheter be advanced under direct visualization- never blindly. Overly aggressive passing of the catheter can open a fistula and lead to tension pneumothorax. Acrylate tissue glue (Histoacryl) is primarily used to seal corneal perforations and embolize vascular malformations. It is also useful for endobronchial closure of proximal bronchopleural fistulas. 13- 16 The fistula is located with the rigid or fiberoptic bronchoscope and the surrounding area cleared of any mucus or other debris. A thin plastic or TeOon catheter is then passed through the suction channel of the bronchoscope and positioned near the fistula. Next, 0.5 to 1 ml of acrylic tissue glue is injected through the catheter to the fistula site (Fig 2). Ifincomplete closure of the BPF occurs, the procedure can be repeated at the same sitting or later. The tissue glue mechanically occludes the fistula and induces a local reactive proliferation of the bronchial mucosa. This prolifera-

FIGURE 2. Tissue glue (Histoacryl) injected through a catheter onto the bronchopleural fistula seen in Figure 1.

tive process is responsible for long-term closure of the fistula. 17 The main technical considerations are as follow:· (1) the glue must not be injected directly through the suction channel but rather through a catheter to avoid damaging the bronchoscope; and (2) the glue solidifies rapidly (in about 10 seconds), making rapid injection necessary. Fibrin glue is used to seal both proximal1s-llll and peripheral BPF. 22 For proximal BPF, the fistula is identified and a catheter passed through the suction channel as described for tissue glue occlusion. One milliliter of concentrated fibrinogen is injected through the catheter, followed immediately by 1 ml of topical thrombin (1,000 units/ml). As the components mix, a fibrin clot forms over the fistula in several minutes. Concentrated fibrinogen is prepared by the blood bank from the patients' own plasma which eliminates the risk of bloodbome infection. For peripheral BPF, the balloon catheter occlusign technique is used to locate the leaking bronchus. The catheter is then placed in the bronchus and the balloon inflated. The fibrin glue is injected as described above and the balloon is left inflated for several minutes while the glue solidifies. The long-term fate of fibrin glue in the lung is not known. In one animal study, fibrin glue was applied to the pleural side of a BPF. Histologic examination, performed at three months, indicated that the glue was totally resorbed and no foreign body reaction was discernible. 21 Gelfoam can also be used to occlude a peripheral BPF. 23 The segments leading to the BPF are identified as previously described. Gelfoam is then cut into small strips (0.25 X 0.5 X 2.0 em), moistened with saline solution, placed into the suction channel of the flexible bronchoscope (with the aid of forceps), and flushed with saline solution into the affected segmental bronchus. This is repeated until the bronchus is completely occluded with a Gelfoam plug. The placement of Gelfoam can be more easily accomplished through a rigid bronchoscope which can be used for accessible fistula. Pleural suction at 30 em H 20 is maintained for at least five days to allow full lung expansion. The theoretic advantages to the use of. Gelfoam in this situation include its availability, ease of administration, and that it is completely phagocytized within one month. Endobronchial placement of a lead shot plug has been successful in the occlusion of a peripheral BPF in a patient on mechanical ventilation. 114 The technique described by the authors is as follows: (1) the subsegment leading to the BPF is identified as previously described; (2) a guide wire is passed through the suction channel of the fiberoptic bronchoscope into the affected bronchus; (3) the bronchoscope is then withdrawn over the guidewire; (4) a No. 3.0 split shot fishing weight is sterilized in gluteraldehyde, crimped

over a short strand of mersilene suture (to facilitate bronchoscopic retrieval of the lead shot), and perforated with an 18 gauge needle; (5) the lead shot is then advanced over the guidewire and pushed into place by the bronchoscope (which is also threaded over the guidewire). It can later be removed by bronchoscopy to avoid any long-term sequela. Lead is reported by these authors to cause only minimal tissue reaction. Balloon catheter occlusion of BPF has also been proposed. An experimental study has shown satisfactory occlusion of peripheral BPF in dogs with detachable balloons. 25 However, we are not aware of the use of detachable balloons in humans. A technique has been described using an atrial septostomy catheter to occlude a peripheral BPF until surgery could be performed.• The catheter was fluoroscopically guided into each of the segmental bronchi on the affected side. Trial inflations of the balloon were performed in each of the segmental bronchi until the air leak stopped. The balloon was then inflated with a minimal amount of dilute contrast material and left in place. The balloon was deflated every 24 hours for two hours, then reinflated. Selective intrabronchial injection ofdoxycycline and autologous blood can also occlude peripheral BPF. 27 In the reported case, 1 ml (20 mg) of doxycycline was injected and immediately followed by 15 ml of blood. This healed a bronchopleural air leak that had been unresponsive to three months of conservative therapy. The authors do not specifically address their management of pleural suction during the procedure. We maintain pleural suction at 20 em H 20 during the procedure. Once the air leak is stopped, we discontinue suction and put the chest tube to underwater seal. This decreases the likelihood of the blood patch being dislodged and the BPF re-opened. Any of the above techniques can be used in patients on mechanical ventilation. These patients are usually on positive pressure ventilation (with attempts to control peak pressure and PEEP) on high-frequency jet ventilation.• 12 They should be adequately sedated, under optimum cough control, and have ventilatory and oxygenation requirements maintained during the procedure. Again, the equalization of pressure across the BPF may be a factor in keeping the sealant in place during the reparative process. CoNCLUSIONS

In 1977, Ratliff and colleagues114 first reported successful control of a BPF by endobronchial occlusion with a lead shot. That same year, Hartmann and Rausch described, "A new therapeutic application of the fiberoptic bronchoscope," closure of a BPF by endoscopic application of tissue glue. 13 Since that time, numerous case reports and small series of patients have documented successful endobronchial CHEST I 97 I 5 I MAY, 1980


control of BPF with the fiberoptic bronchoscope. Conservative management, rigid bronchoscopy, and surgical intervention are first line therapy for the majority of patients with BPF. Unfortunately, some who fail to heal with conservative management are also extremely poor surgicaVanesthesia risks due to respiratory compromise, comorbid medical conditions, or generalized debilitation. We have outlined several therapeutic options that can be utilized in these difficult clinical settings. While there are no large series to document efficacy of these procedures, we are encouraged by reports of successful application in select patients. Further experience with these techniques, both positive and negative, will clarify their exact role in the bronchoscopist's armamentarium. REFERENCES 1 Malave G, Foster ED, Wilson JA, Munro DD. Bronchopleural fistula, present-day study of an old problem. Ann Thorac Surg 1971; 11:1-10 2 Hankins JR, Miller JE, AttarS, Satterfield JR, McLaughlin JS. Bronchopleural fistula, thirteen-year experience with 77 cases. J Thorac Cardiovasc Surg 1978; 76:751Hi2 3 Steiger Z, Wilson RF. Management of bronchopleural fistulas. Surg Gynecol Obst 1984; 158:267-71 4 Pierson DJ, Horton CA, Bates pw. Persistent bronchopleural air leak during mechanical ventilation, a review of 39 cases. Chest 1986; 90:321-23 5 Frytak S, Lee RE, Pairolero PC, Arnold PG, Shaw JN. Necrotic lung and bronchopleural fistula as complications of therapy in lung cancer. Cancer Invest 1988: 6:139-43 6 Hoier-Madsen K, Schulze S, Pederson VM, Halkier E. Management of bronchopleural fistula fOllowing pneumonectomy. Scand J Thor Cardiovasc Surg 1984: 18:263-66 7 Koval JC, Joseph SG, Schaefer PS, Tenholder MF. Fiberoptic bronchoscopy ':ombined with selective bronchography, a simplified technique. Chest 1987; 91:776-78 8 Baldwin JC, Mark JBD. Treatment of bronchopleural fistula after pneumonectomy. J Thorac Cardiovasc Surg 1985; 90:81317 9 Phillips YY, Lonigan RM, Joyner LR. A simple technique for managing a bronchopleural fistula while maintaining positive pressure ventilation. Crit Care Med 1979; 7:351-53 10 Powner DJ, Grenvik A. Ventilatory management of life-threatening bronchopleural fistulae, a summary. Crit Care Med 1981;


9:54-58 11 Hazerian TE, Berrezueta R, Pittokopitis K, Buckle FG, Robinson L. Technical consideration of synchronized chest tube occlusion in bronchopleural fistula. Crit Care Med 1983; 11:484 12 Bishop MJ, Benson MS, Sato P, Pierson DJ. Comparison of high-frequency jet ventilation with conventional mechanical ventilation for bronchopleural fistula. Anesth Analg 1987; 66:833-38 13 Hartmann W, Rausch V. A new therapeutic application of the fiberoptic bronchoscope. Chest 1977; 71:237 14 Keller FS, Rosch J, Barker AF, Dotter cr. Percutaneous interventional catheter therapy for lesions of the chest and lungs. Chest 1982; 81:407-12 15 Roksvaag J, Skalleberg L, Nordberg C, Solheim K, Hovik B. Endoscopic closure of bronchial fistula. Thorax 1983; 38:696-97 I6 Torre M, Chiesa G, Ravini M, Vercelloni M, Belloni PA. Endoscopic gluing of bronchopleural fistula. Ann Thorac Surg 1987; 43:295-97 17 Menard Jw. Prejean CA, Tucker WY. Endoscopic closure of bronchopleural fistulas using a tissue adhesive. Am J Surg 1988; 155:415-16 18 Jessen C, Sharma P. Use of fibrin glue in thoracic surgery. Ann Thorac Surg 1985; 39:521-24 19 GloverW, Chavis TV; DanieiTM, Kron IL, Spotnitz WD. Fibrin glue application through the flexible fiberoptic bronchoscope: closure of bronchopleural fistulas. J Thorac Cardiovasc Surg 1987; 93:47o-72 20 Onotera RT, Unruh HW. Closure of a post-pneumonectomy bronchopleural fistula with fibrin sealant (Iisseel). Thorax 1988; 43:1015-16 21 McCarthy PM, Trastek VF, Bell DG, Butterman GR, Piehler JM, Payne WS, et al. The effectiveness of fibrin glue sealant for reducing experimental pulmonary air leak. Ann Thorac Surg 1988; 45:203-05 22 Regel G, Sturm JA, Neumann C, Schueler S, Tscherne H. Occlusion of bronchopleural fistula after lung injury, a new treatment by bronchoscopy. J Trauma 1989; 29:223-26 23 Jones DP, David I. Gelfoam occlusion of peripheral bronchopleural fistulas. Ann Thorac Surg 1986; 42:334-35 24 Ratliff JL, Hill J, Tucker H, Fallat R. Endobronchial control of bronchopleural fistula. Chest 1977; 71:98-99 25 PaceR, Rankin RN, Finley RJ. Detachable halloon occlusion of bronchopleural fistulae in dogs. Invest Radiol1983; 18:504-06 26 Ellis JH, Sequeira Fw, ~ber TR, Eigen H, Fitzgerald JF. Balloon catheter occlusion of bronchopleural fistulae. Am J Radiol1982; 138:157-59 27 Lan R, Lee C, Tsai Y, Wang W, Chang C. Fiberoptic bronchial blockade in a small bronchopleural fistula. Chest 1987; 92:94446

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Bronchoscopy in the management of bronchopleural fistula.

bronchoscopy Bronchoscopy Fistula* in the Management of Bronchopleural MAJ john E. McManigle, M.D.; MAJ Gardner L. Fletcher, M.D.; and COL Michael F...
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