A Modified Technique for the Management of Bronchopleural Fistula in Ventilator-Dependent Patients: A Report of Two Cases

Abstract

The management of a ventilator-dependent patient with a large bronchopleural fistula may be extremely difficult. Much of the volume provided by the ventilator may be lost through the fistula, resulting in inadequate ventilation. The difficulty is compounded when positive end-expiratory pressure (PEEP) is required, which tends to keep the fistula patent. PEEP may also be difficult to maintain in the presence of a large leak. We used several modifications of two previously described techniques to develop a system that safely reduced the air leaks from the bronchopleural fistulae of two ventilator-dependent patients. Our system allowed us to occlude the chest tube during the inspiratory phase of the ventilator, which eliminated the air leak through the chest tube during inspiration. PEEP could also be applied to the chest tube whenever it was applied to the airway to minimize the transpulmonary pressure gradient. A bleed valve permitted further manipulation of the transpulmonary pressure gradient during expiration so as to facilitate the drainage of any residual pneumothorax. A collection chamber with a shut-off valve provided for the easy collection and removal of small amounts of pleural fluid that accumulated. One-way valves prevented the entry of air into the pleural space from the outside. As an added precaution, our system could immediately be connected to suction in the event that another air leak resulted in the reaccumulation of a large pneumothorax. This system worked successfully in the two patients discussed here. Although both expired, their deaths were not due to an inability to provide adequate ventilation because of the presence of bronchopleural fistulae.