BRONCHOPLEURAL fistula pptx.............

Anesthesia and Intensive care..

1. BRONCHOPLEURAL FISTULA Presenter: Dr Andal Priyanka Moderator: Dr. Pratiti

2. Case report A 15-year-old male, weighing 49 kg was brought to the emergency Department 19 days after an injury to the right side of his chest by the steering wheel of a tractor. Patient had complaints of pain over the right side of chest and breathlessness soon after the injury. He had no upper airway obstruction and there was no other associated injury. He was initially treated at a peripheral hospital, where intercostal drainage (ICD) was placed & on fiberoptic bronchoscopy near complete transaction of right main bronchus with bronchopleural fistula.

3. 0/E:conscious, GCS – 15/15. PR =92 beats/min, BP= 120/76 mmHg, RR 19/ min and SPO2was 92–97% on room air. On auscultation, air entry was absent on the right side of the chest. There was collection of 250 ml of straw colored fluid in the right ICD. Chest compression test was negative. There were no other associated injuries. ABG (pH= 7.46, PCO2 =37, PO2 = 70, HCO 3 =26.8,BE= 2.5). Chest radiograph and Computed Tomography (CT) Scan showed right sided pneumothorax with collapsed lung, absent bronchopulmonary markings with ICD in situ

4. definition A Broncho pleural fistula (BPF) is a communication between the pleural space and the bronchial tree

5. CLASSIFICATION * ALVEOLOPLEURAL FISTULA(APF ): Pulmonary pleural communication distal to segmental bronchus and pleural space. Common after lung resection except pneumonectomy BRONCHOPLEURAL FISTULA: Communication between mainstem , lobar or segmental bronchus or the pleura lined cavity * Pleural disease by Richard Light 6 th edition Anesthesia for thoracic surgery – Slinger P

6. Cerfolio Air leaks Classification* Continuous (C): largest, uncommon Eg : BPF on MV Inspiration(I): second largest, Eg : APF, small BPF on MV Expiration(E): after lung surgery suggestive of APF Forced Expiration(FE): Eg : coughing, common after lung resection HEALING *Pleural disease by Richard Light 6 th edition

7. AETIOLOGY POSTOPERATIVE Incidence 1.5 to 28% for pnemonectomies (2% - 11%) and for lobectomies (0.5%) Mortality: 5% to 70% Risk of dehiscence * : 1.8% : manual suture 5.0% : stapling device 1.9% : reinforcement suture at distal side 1.0% : reinforcement suture at proximal side * Sonobe et al. Eur J Cardiothorac Surg 2000; 18:519–523

8. Perioperative risk factors Advanced case ( main bronchus) Previous ipsilateral thorocotomy H/O chemotherapy and radiotherapy H/O fever, steroid, diabetes Anemia, leukocytosis , ESR, hypoalbuminemia Residual tumor on stump Excess peribronchial , paratracheal dissection Intrathoracic chemotherapy Tightness of sutures Continous Mechanical ventilation > 24hrs *Sato et al. Nippon Kyobu Geka Gekkai Zasshi 1989;37:498–503

9. Nonpostoperative Infection: bacterial , fungal , parasitic Spontaneous rupture of bullae , cyst After procedures Persistent spontaneous pneumothorax . Thoracic trauma Erosion of bronchial wall : by malignancy, foreign body, chronic inflammation GERD

10. Clinical presentation ** Varoli et al* classified according to time of onset Early - 1 to 7 days Immediate – 8 to 30 days Late - more than 30 days Usually presents after 7-15 days following lung resections Early indicators- reappearance of fever, increased cough with purulent or serosanguinous sputum *Varoli F et al . Endoscopic treatment of bronchopleural fistulas. Ann Thorac Surg 1998;65:807-9 .

11. Acute BPF Life-threatening , due to tension pneumothorax or asphyxiation secondary to massive pulmonary flooding, Clinical presentation sudden onset of dyspnoea, hypotension, subcutaneous emphysema, cough with expectoration, There may be antecedent tracheal shift Acute form is typically related to stump dehiscence & requires immediate re-exploration.

12. Subacute chronic Ass infection, I/C state Generalised wasting Malaise Fever minimally productive cough It may be associated with an infectious process and there may be coexistant fibrosis of the pleural space and mediastinum **

13. diagnosis CLINICAL After pneumonectomy - development of sudden onset dysponea , subcutaneous emphysema After lobectomies - persistent air leak, purulent drainage and expectoration of purulent material After ICD removal – fever, purulent sputum, new air fluid on CXR

14. CXR Steady increase in intra pleural space Appearance of new air fluid level(indicates level of BPF) Drop in air fluid level more than 2cm(in absence of chest tube) Development of tension pneumothorax

15. Bronchoscopy ( diagnostic & therapeutic) Evaluation & localization of fistula Instillation of methylene blue through bronchoscope – appearance of dye in chest drain, sputum Visualisation of continuous return of air bubbles on bronchial wash FOB aided placement of balloon-tipped catheter in selective airway: inflation of balloon eliminates leak Combined FOB and Capnography : polyurethane catheter passed through br.scopic channel and introduced into different bronchi BPF suggested by loss of capnographic tracing: affected bronchus communicates to atmosphere through chest tube I ntroduction of sealants into the fistulous tract

16. CT scan Ventilation scintigraphy CT Bronchography Chest tube

17. management of BPF SURGICAL MEDICAL early & large postoperative fistula chronic & small fistula associated with infections MORTALITY 1 2 3

18. HOW TO ADDRESS THE CONSEQUENCES?

19. ROLE OF CHEST TUBE IN BPF Indications High flow BPF Drainage of empyema Pneumothorax Advantages Add positive intrapleural pressure during expiration to reduce air leak and maintain PEEP Intermittent occlusion during inspiratory phase to decrease BPF flow Useful in ARDS Chest tube can be used for pleurodesis

20. Disadvantages Can function as foreign body and delay healing Predispose to infection at insertion site and pleural space Loss of tidal volume Abnormal gas exchange Inappropiate ventilator cycling

21. Therapeutic Bronchoscopy in BPF 1977 - Ratliff et al pioneered endoscopic management of BPF INDICATIONS Suitable for small fistulas(<5mm). Proximally located fistulas- main stem, lobar, or segmental bronchi are more suitable. Useful for patients who are not proper candidate for surgery.

22. Sealing compounds Injecting absolute ethanol directly into submucosal layer of a fistula is first-line therapy for patients with a postoperative central BPF with an orifice < 3 mm Lead Shots Polyethylene Glycol Cyanoacrylate Glue , Fibrin Glue , Blood Clot Antibiotics Albumin- Glutaraldehyde Tissue Adhesive Gel Foam Coils Intrabronchial stents, valves Calf Bone Balloon Catheter Occlusion Cellulose, silver nitrate *Kinoshita et al. Chest 2000; 17:790–795 * Potaris et al Med Sci Monit 2003; 9:P179–P183 *Chest 2008; 133(6): 1481-4

23. Surgical procedures for BPF Revision of bronchial stump ( CLAGETT procedure) Decortication of lung Closure of fistula with muscle flap from intercostal space Thoracoplasty with pedicle muscle flap to cover bronchial stump. Resection of diseased chronically infected segments First stage: chest cavity drainage consisting of muscle flap operation  Second stage: After aggressive nutritional & physical rehabilitation, second procedure for chest cavity obliterationwith an omental flap is performed * Turk et al. Plastic Surg 2000; 45:560–564

24. Preoperative assessment HISTORY EXAMINATION Estimation of volume loss through fistula Check bubble flow through chest drain- continous (large) or intermittent (small) 2 . Quantification of size of BPF- Difference of inhaled vs exhaled tidal volumes Intubated patients: direct attatchment of spirometer to ETT tube Non intubated patients: tight fitting mask and fast responding spirometer

25. INVESTIGATIONS Routine – CBC, RBS, SE, KFT, LFT, Coag profile urine r/m, CXR , ECG, ECHO Specific – ABG, Bronchoscopy , CT, VS

26. Preoperative preperation Optimize respiratory function(smoking, infection) Optimize associated diseases Predict difficult endobronchial intubation Predict desaturation during OLV If chest tube present- check for patency Mild sedation A B C

27. Approach

28. ANESTHETIC CONCERNS Temperature Fluid Emergence Post op icu stay Pain control Mortality

29. monitoring* ASA I ASA II – ECG , SpO2, NIBP, EtCO2, Temperature urine output. Thoracic surgery: (Paw) 1) Arterial line - IBP 2) central line 3) side stream spirometry (NR) 4) TEE 5) EDU *Hemodynamic monitoring in thoracic surgery – Jacob Raphael 2017

30. Induction* *James Mitchell (December 24, 2003) Avoid CMV Avoid clamping drain Avoid CMV Avoid CMV Avoid suction to drain Isolate lung ASAP!! !

31. Position for induction- Head up with 30 degree lateral tilt keeping diseased lung down Options to secure airway include 1)Awake fibreoptic intubation with DLT,- Induction of GA once lung isolation achieved Safest but technically difficult Requires patient cooperation and thorough airway topicalization 2) Induction of GA maintaining maintaining spontanoeus ventilation, DLT insertion when deep , aviod IPPV 3) If airway thought to be easy, Modified RSI can be done avoiding IPPV until lung isolation achieved Thoracic epidural + IV sedation (SLT safe to use: if fistula small, chronic, uninfected) * Anesthesia for thoracic surgery – Slinger P

32. Mechanical ventilation in BPF* GOALS CHALLENGES

33. To keep reduced airway pressures Low tidal volume Limiting PEEP Short inspiratory time ( high PIFR) Reducing respiratory rate Reducing minute ventilation Pleural decompression Chest drain: lowest possible suction pressure or no suction as increased suction pressure increases the flow. For large fistula : Independent lung ventilation or HFJV can be considered *Pierson DJ. Management of bronchopleural fistula in patients on mechanical ventilation.

34. Chest tube manipulation Intermittent inspiratory chest tube occlusion Application of intrapleural pressure at expiration Independent lung ventilation CPAP High frequency ventilation Extracorporeal oxygenation WHEN CONVENTION FAILS

35. Small tidal volume Lower airway pressure

36. Gas transport in hfv Longitudinal gas transport : Coaxial flow Molecular diffusion Mixing of fresh & exhaled gas : Lateral diffusion Turbulent flow at airway bends & bifurcations Intra-alveolar pendelluft Heart beat Most proximal alveoli by bulk flow Suboptimal humidification Inspissation of airway secretions Necrotizing tracheobronchitis Gas trapping COMPLICATION WITH HFV

37. Hfv in bpf Superior to conventional ventilation in controlling P CO 2 & P O 2 in proximal BPF & normal lung parenchyma Controversial in peripheral BPF with parenchymal disease (e.g. ARDS) Initial settings: Begin with MAP similar to or slightly lower than that of conventional ventilation Use higher frequency (13-15Hz) Amplitude to achieve minimal chest movement

38. HYPOXIC PULMONARY VASOCONSTrICTION * 50% Stimulus : PAO2 Inhibitors : Infection Vasodilators Hypocarbia Hypothermia Inhalational Surgery * Miller 8 th Edition

39. Maintainence * Inhalational agents and narcotics or epidural High FiO2 IPPV to healthy lung Ventilate healthy lung with normal tidal volume. Ventilate affected lung with smaller volume Titrate ventilation to normal PaCO2 Blood loss Fluid management EMERGENCE : Avoid high Paw ( SIMV, Hand ventilation) Examine airway – suction , extubation *Thoracic surgery -James Mitchell (December 24, 2003 )

40. Fluid therapy in thoracic surgery CVP SPV SVV PPV EVLW CO CI

41. Assesed EVLWT, PaO2/FiO2,blood lactate,ScvO2,BE,CVP,CI,GEDI Meta analysis have shown that GDFT is better than conventional

42. Pain management Thoracotomy – 80% Atelectasis Pneumonia RF DVT Types Acute chronic Thoracotomy T4 – T6 CHEST DRAIN T7 – T8 MEDIASTINAL PLEURA X CENTRAL DIAPHRAGMATIC PLEURA C3 – C5 I/L SHOULDER PAIN BRACHIAL PLEXUS

43. Modalities* Opioids NSAIDS ketamine Dexmed Gabapentin *Post thoracotomy pain management - Kathrine LOCAL ANESTHETICS SYSTEMIC DRUGS OTHERS Cryoablation TENS