Coordinator : Dr. SugandhaModerators : Dr. Geetha N K

:Dr. Rajeev D S

Presenter : Dr. Frank Amal

BRONCHOPLEURAL FISTULA (BPF)

DEFINITON

A persistent abnormal communication between tracheobrochial tree and pleural cavity

Cutaneous BPF → additional communication to the surface

CAUSES OF BPF

Breakdown of suture/staple line following lung resection

More common following right pneumonectomies

Manual Vs stapled bronchial closure.

Rupture of cavityBulla

Cyst

Abscess

Bleb

CAUSES OF BPF

Erosion of bronchial wallEmpyema

Pneumonia

TB.

Neoplasm

Foreign body

CAUSES OF BPF

Penetrating trauma

IatrogenicBarotrauma

Thoracocentesis

Tracheobronchial biopsy

Traumatic intubation

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

Disruption involves the the tracheobronchial tree.The disruption occurs when a 1-way valve forms, allowing air inflow into the pleural space and prohibiting air outflow. The volume of this non absorbable intrapleural air increases with each inspiration because of the 1-way valve effect. As a result, pressure rises within the affected hemi thorax. As the pressure increases, the ipsilateral lung collapses and causes hypoxia.

In ventilated patients, suspect bronchopleural fistula when increased pleural pressures causes

An increase in peak airway pressure in order to deliver the same tidal volume.

Decreased expiratory volumes secondary to air leakage into the pleural space and

Increased end-expiratory pressure, even after discontinuation of PEEP

PFT - T.V , FRC, R.V, FEV1,

PATIENT IN THE LATERAL DECUBITUS POSITION WHEN AWAKE AND WHEN

ANESTHETIZED

ANAESTHETISED, OPEN CHEST, LATERAL DECUBITUS POSITION

•The nondependent lung is well ventilated but The nondependent lung is well ventilated but poorly perfusedpoorly perfused•The dependent lung is poorly ventilated but The dependent lung is poorly ventilated but well perfused .well perfused .

• Opening the chest Opening the chest •↑ ↑ nondep lung nondep lung compliancecompliance• larger part of TV larger part of TV goes to the goes to the nondependent lung nondependent lung

•Paralysis Paralysis • Larger part of TV Larger part of TV goes to the goes to the nondependent lung nondependent lung because P of the abd because P of the abd contents pressing contents pressing against the upper part against the upper part of the diaphragm is of the diaphragm is minimal.minimal.• So easier for IPPV So easier for IPPV to displace this lesser to displace this lesser resisting dome of the resisting dome of the diaphragm.diaphragm.

V/Q MISMATCH & LATERAL POSITION

Awake AnaesthetisedV Q V Q V Q

ND D

Early findings Chest pain

Dysponea

Anxiety

Tachyponea

Tachycardia

Hyper resonance of the chest wall on the affected side

Diminished breath sounds on the affected side

Late findings Decreased level of consciousness

Tracheal deviation toward the contralateral side

Hypotension

Distension of neck veins (may not be present if hypotension is severe)

Cyanosis

Further pressure build-up causes the mediastinum to shift toward the contra lateral side and impinge on both the contra lateral lung and the vasculature entering the right atrium of the heart.

This condition leads to worsening hypoxia and compromised venous return.

The inferior vena cava is the first to kink and restrict blood flow back to the heart.

evident in trauma patients who may be hypovolemic with reduced venous blood return to the heart.

Hypoxia leads to increased pulmonary vascular resistance via vasoconstriction.

Decreasing cardiac output and worsening metabolic acidosis secondary to decreased oxygen delivery to the periphery occur, thus inducing anaerobic metabolism.

If the underlying problem remains untreated, the hypoxemia, metabolic acidosis, and decreased cardiac output lead to cardiac arrest and death.

Infection of contralateral lung

Types Central : 2/3rd due breakdown of pneumonectomy /lobectomy)

Peripheral :1/3rd due to breakdown of distal staple line

Incidence :4.5 %-20% following pnemonectomy

0.5% following lobectomy

PREDISPOSING FACTORS

Technical difficulty with bronchial closure

Residual tumor

Pre Op Irradiation

Diabetes

Infection

Long bronchial stump

Complete pneumonectomy

CLINICAL FEATURES & MGT

Presentation & treatment of post-surgical BPF depend on

Size of the air leakSmall -<3mm

Large>10mm( 20 -50% of tidal volume)

Type of resection

Time of presentationEarly (1st several days of Surgery

Delayed (weeks to years) e.g. empyeme

CLINICAL FEATURES OF POST PNEUMONECTOMY BPF

Acute dehiscence present as Sudden large ↑ in air leak

Various degrees of respiratory distress

Mediastinal shift

Low grade fever and cough

resp. distress & hypoxemia

CXR –sudden drop in air-fluid level

Bronchogram shows escape of dye through broncho- pleural fistula into chest tube

DIAGNOSIS

Clinical

Injection of methylene blue into pleural space → recovery from sputum

Chest X-ray

Broncoscopy,

Bronchography

INVESTIGATION

Complete Blood Count

RBS

CT scan :chest identify empyema cavity and guide location of chest tube placement

Bronchoscopy :location and closure by balloon the BPF

RESUSCITATION

Position :sitting and supported, pneumonectomised side down

Oxygen by face mask

I.V access for saline ,antibiotics and dysarrthymias

Chest drain to remove fluid prevent risk of infection on the opposite lung

Mechanical ventilation if large fistula

Isolate with single or double lumen tube

Surgical closure

POST PNEUMONECTOMY BPF

Delayed BPF managementEarly thoracotomy

Antibiotics

Respiratory support

Debridement & dressing change

Packing the cavity with antibiotic soaked material

Correction of dehydration & malnutrition

Usually heals within 4 to 6 Wks

Otherwise surgical closure

MANAGEMENT

CHEST TUBE MANAGEMENT IN BPF

AIM

Drain pleural space

Re-expansion of remaining lung

Suctioning

COMPLICATION

High mortality due Sepsis

Respiratory failure

Malnutrition

Erosion of pulmonary artery stump

BROCNOPLEURAL FISTULAANESTHETIC

CONSIDERATION

ANAETHESIOLOGIST NEEDED

Diagnostic Bronchoscopy Establishment of closed or open drain systemRepair of acute stump dehiscenceDebridementFistula closure with muscle flap obliterationDecorticationsLung isolationOptimal ventilation in mechanically ventilated patient in ICU

ANESTHETIC CONSIDERATION

Pre op evaluation most essentialPurely on clinical grounds

Poor general conditionLarge BPF→ loss of tidal vol. →V/Q mismatch →hypoxia & hypercarbia Infection, malnutrition, dehydrationRespiratory distress & circulatory collapse ( tension pneumothorax)Hazards of emergency surgery –full stomach

ANESTHETIC CONSIDERATION

SPECIFIC RISK

PPV → large air leak→ insufficient ventilation & oxygenation →enlargement of fistula contamination of contra lateral lung

Hence ,Maintain spontaneous ventilation till affected side is isolated

ANESTHETIC CONSIDERATION

Goals

1. Minimization of airflow through the fistula

2. Adequate gas-exchange in unaffected lung

3. Avoid hypoxemia at any cost

4. Avoid positive pressure ventilation until fistula isolated

5. Avoidance of tension pneumothorax

6. Protection against contamination of remaining lung

ANESTHETIC CONSIDERATION

Improve general condition

Oxygen

I/V fluid

Antibiotics

Circulatory support

Chest tube drainage

FOB

ANESTHETIC CONSIDERATION

Pre op investigationIn addition to routine 1. CXR2. PFT3. ABG4. Bronchoscopy 5. Evaluation of loss of tidal volume

1. Intermittent or continuous air bubbles through chest tube

2. Measuring expired tidal volume

BRONCHOSCOPY

Topical anaesthesia Head end elevated

Ultra short acting narcotics and topical anaesthesia

IV induction with short acting agents with single lumen ETT and Bronchoscopy during aponea period

If hypoxia occurs ,advance over bronchoscope ETT into unaffected lung bronchus, saturation improves ,tube pulled back for FOB EXAMINATION

Establish lung isolation –DLT.

FOB through Tracheal Lumen

Inhalation induction maintaining Spontaneous Ventilation

Disadvantage coughing ,cross contamination

TIVA with spontaneous ventilation–margin of safety between inadequate and excess depth

INDUCTION, INTUBATION, ISOLATION

Patient sitting up with affected side dependent

PPV should be withheld until fistula is isolated

Suction on chest tube should be discontinued to ↓loss of tidal volume

INDUCTION, INTUBATION, ISOLATION

AWAKE INTUBATION

Theoretically attractiveSpontaneous ventilation until

Ability to cough IPPV

Practically difficultSick hypoxic patient unable to cooperate

Cough when LA. spray applied

Penetration of mucosa by LA impaired

GENERAL ANESTHESIA WITH SPONTANEOUS VENTILATION

Advantage1. More patient comfort2. Less incidence of coughing

Disadvantage 1. Altered kinetics of inhalational agent due to

fistula2. Hypotension with inhalational agents 3. Spontaneous Ventilation may fail before depth is

sufficient without coughing

RAPID SEQUENCE INDUCTION

Atraumatic intubation with no coughing

Safe only if the tube can be sited correctly & reliably at first attempt

DisadvantageExperienced anaesthiologist and staff needed

Endobronchial blockers are useless

CHOICE OF ISOLATION

• Double lumen tube-tip cannot be controlled after the tip enters the larynx

Lumen on fistula side should be occluded before giving positive pressure ventilation to prevent pressure building up within

In failure to Intubate consider Endotracheal Intubation.

Single lumen Endobronchial tube-placed under direct vision

If fistula is small and uninfected → standard ETT can be used

Gentle manual ventilation Drain chest Apply pressure to drain for adequate gas

exchange with each positive pressure ventilation

Disadvantage: Risk of surgical emphysemaRisk of adhesion Drain cannot be guaranteed

Bronchial blockers

DLT most commonly used

TECHNIQUE

Premedication → small dose of anxiolytics and anticholinergics ( inj. Atropine)

Disadvantage Patient has already tachycardia

Interfering with mucocilary clearance

AdvantageDecreases bronchial secretion and saliva

Transportation to O TPatient sitting with pneumonectomised side dependent

Drain clamped and disconnected

Re establish free drain in O T before induction

Oxygen by mask

IN THE O.T

Patency of drain is checked

Reassure the patient

Oxygen supplementation

Check suction apparatus ,Endobronchial equipment and emergency drugs

MONITORS

ECGPulse OximeterNIBPPNSEnd Tidal CO2Temperature probeOesophageal sthescopeCVP

TECHNIQUE

Position :Patient induced and intubated in sitting position and anesthesiologist stands on a stool behind the head PreoxygenationSleep dose of thiopentone and a fully paralyzing dose of suxamethoniumEndobronchial Intubation is inserted without prior inflation of the lung

Bronchial cuff is secured Patient is ventilated with oxygenThen lowered to supine positionEndobronchial and pharyngeal toilet completedPatient turned to lateral position, chest re exploredBleeding is unusual if excessive contamination

At the end of surgery → test integrity of airway →pressurizing & and looking for air bubble in a saline filled hemi thorax

TECHNIQUE

Reestablish spontaneous ventilation at the end if at all possible

IPPV with low peak inflation pressure if spont. not possible

HFPPV is preferred to conventional mechanical ventilation

VENTILATORY MANAGEMENT

Provide ventilation only to one lung

Allowing the fistula to heal

Not possible in patients with associated pulmonary pathology →due to large shunt

Unilateral PEEP may also ↑ the shunt

VENTILATORY MANAGEMENT

Differential lung ventilation

DLT with independent volume settings for each lung by 2 synchronized ventilators

Normal lung →ventilate normally

Diseased → TV & PEEP kept reduced

Level of CPAP →”just below critical opening pressure of fistula”

HIGH FREQUENCY JET VENTILATION

ADVANTAGE– Minimal loss of TV

– Fistula heal more quickly

– Airway resistance, pulm. Compliance will have minimal influences

– Low airway pressure

– Spontaneous efforts are abolished→ less sedation & no need of paralysis

VENTILATORY MANAGEMENT

MONITORING

1. Measuring continuously volume of gas passing from the chest tube by inserting a flow tube sensor

2. Other less reliable methods Assessing amount of air bubble Difference between inspired and expired tidal volume

LUNG CYST

LUNG CYST

A thin walled air filled cavity with in the lung which is large enough to be seen on a plain x-ray.

Cysts and bullae can be considered together

Classified as congenital & acquired

LUNG CYST

CongenitalBronchogenic cyst

Congenital cystic adenomatiod malformation

Cong. Lobar emphysema

Acquired Bullous emphysema

Hydatid cyst

Traumatic lung cyst

LUNG CYST

Hazards in pathophysiologySmall cyst rarely cause symptoms

Cyst become problematic if They become enlarged & cause mass effect (tension cyst)

If they rupture & create a pneumothorax

If they become infected

Hydatid cyst ,pulmonary sequestration and CCAM are usually uninfected, without bronchial communication ,small, asymptomatic

LUNG CYST

Infected cystCommunicating more prone for recurrent infection

Fever, cough, purulent sputum, occasional hemoptysis

Tension cystCommunicating cyst can trap by ball valve mechanism

causes rapid expansion, pneumothorax & mass effect

Acute cardio - respiratory instability

LUNG CYST

Emphysematous bullaeFormed due to destructive process of emphysema

Air can be trapped with in bullae because of preferential inflation & ↓ elastic recoil

Expiratory obstruction of emphysema contribute to expansion

Ball valve mechanism causes sudden rapid expansion

LUNG CYST

Pathophysiology– Space occupying lesion→ impaired expansion of

lung →↓ elastic recoil of lung parenchyma →↑airway resistance

– Distortion of bronchial anatomy → further increase airway obstruction

– Flattened diaphragm and hyper expanded rib cage →disadvantage for mechanics of respiration

– Can be a source of ↑dead space and WOB

HYPOTENSION

Decreased venous return due to increased intrathoracic pressureExtrinsic restriction of diastolic ventricular filling (tamponade effect)Mediastinal shiftTreatment

Restore venous return by fluids , vasopressor and reduce the volume of cyst by surgical decompression or lung isolation (DLT)

Patho physiology

The major types of pneumothorax are:

Open pneumothorax

Closed pneumothorax

Spontaneous pneumothorax -<40yrs.

Pulmonary barotrauma -mechanically ventilated

Air can enter the mediastinum (the space in the center of the chest between the lungs), especially during an asthmatic attack,

When a lung biopsy specimen is taken at the time of Bronchoscopy

Thoracentesis (removal of fluid from the pleural space), the pleura lining the lung may be penetrated,

CT scan through the lower lobes, lung window display, shows a thin-walled cyst in the left lower lobe (arrow).

Insertion of chest drain

Underwater chest drainThe site is between the 4th and 7th intercostal spaces, between the mid-axillary and anterior axillary lines.

Aseptic technique, infiltrate skin and subcutaneous tissues with local anaesthetic.

Incise chest wall 2 cm below proposed site of insertion. Perform blunt dissection using artery forceps through to the pleural cavity.

Using the tip of finger, sweep adherent lung away from the insertion site. Insert the drain into the pleural cavity and slide into position (usually towards the apex). Connect the drain to an underwater seal device.

Perform a purse-string suture around the puncture site to aid sealing after removal.

Some chest drains come with a flexible trocar, thus avoiding risk of trauma.

The underwater seal deviceThe effective drainage of air, blood or fluids from the pleural space requires an airtight system to maintain sub atmospheric intrapleural pressure. This allows re-expansion of the lung and restores Hemodynamic stability by minimizing mediastinal shift. The basic requirements are a suitable chest drain with minimal resistance, an underwater seal and a collection chamber.

ICD

The drainage tube is submerged to a depth of 1-2 cm in a collection chamber of approximately 20 cm diameter.

This ensures minimum resistance to drainage of air and maintains the underwater seal even in the face of a large inspiratory effort.

The chamber should be 100 cm below the chest as sub atmospheric pressures up to -80 cmH2O may be produced during obstructed inspiration. Drainage can be allowed to occur under gravity, or suction may be applied.

The underwater seal acts as a one-way valve through which air is expelled from the pleural space and prevented from re-entering during the next inspiration

Retrograde flow of fluid may occur if the collection chamber is raised above the level of the patient

Absence of oscillations may indicate obstruction of the drainage system by clots or kinks, loss of sub-atmospheric pressure or complete re-expansion of the lung

 Persistent bubbling indicates a continuing bronchopleural air leak

The collection chamber should be kept below the level of the patient at all times to prevent fluid being siphoned into the pleural space. Clamping a pleural drain in the presence of a continuing air leak may result in a tension pneumothorax

Pre-operative assessment

Pre-operative preparation

ANESTHETIC CONSIDERATION

Infected cyst → usually communicate with tracheo bronchial tree & pose a risk of contamination

– Secure lung isolation rapidly

– Drainage with antibiotics should precede surgery

ANESTHETIC CONSIDERATION

Large cystLarge cyst can never be ignored whether it is in a symptomless or breathless patient

They compress adjacent lung

Likely to enlarge when N2O is used

Enlargement → resp. distress, rupture, pneumothorax

ANESTHETIC CONSIDERATION

May be inflated preferentially during mechanical ventilation → inefficient gas exchange

Rapid enlargement if communication is valvular

Cyst may rupture in closed chest and cause pneumothorax

ANAESTHETIC CONSIDERATION

Local anaesthesia is a suitable optionGA is given avoiding nitrous oxideAvoid mechanical ventilation or IPPV but spontaneous respiration is maintained In mech. Ventilation minimize peak inflation pressureFacilities for prompt drainage should be ready Endobronchial intubation avoided during emergency surgery

Gradual enlargement of cyst usually missed

Ruture of cyst is followed by respiratory distress bronchospasm ,marked resistance to inflation and mediastinal shift

Presence surgical drapes makes auscultation difficult

ICD inserted and attached to under water seal without suctioning, it does not interfere with adequate ventilation

THORACOTOMY

Surgery indicated if it interfere with PFT

Usually Plication Or Obliteration Of Cyst Done

Spontaneous ventilation and nitrous oxide avoided until chest is opened

DLT for single or both lung ventilationFor generalized emphysema

Single lumen if trachea distorted and if isolated lung cyst and opposite lung is healthy

ETT Intubation gentle positive pressure ventilation by hand

“Period of risk”-induction to opening of chest and surgeon in control of the cyst

ANESTHETIC CONSIDERATION

IN BILATERAL LESIONS

The compromised lung should be operated

Expanding cyst / pneumothorax may develop in non – operative lung, this will produce hypoxemia, hypotension during OLV

LUNG ABSCESS

Fluid filled cavity unlikely to increase in size

Liable to rupture during manipulation

DLT to isolate the lobe containing the cyst

COMPLETE PROTECTION TO OPPOSITE LUNG AND ROUTE FOR SUCTION

Endobronchial blocker

TREATMENTAntibiotics

If it rupture :postural drainage

ComplicationBPF as long as infection persist

HYDATID CYST

Mostly in sheep rearing countries

Pathophysiology

Enlarge and form daughter cyst or Rptures

Calcify

Secondary cyst

Anaphylactic reaction

Difficult to treat

Removal without spillage

Lobectomy if infected or large cyst

Small cyst enucleated

Aspiration and 10% formalin to kill scolices

Formalin socked swabs used during operation

Cryoprobes

Silver nitrates 0.5%

DLT –if cyst rutures

Median sternotomy or b/l thoracotomy for cyst involving both lungs

Post analgesia

ANESTHETIC CONSIDERATION

Post operative leaks are major source of morbidityEffective reexpansion by recruitment maneuvers Prevented by

Minimizing ventilatory pressure and volume Tailoring the anesthetic technique for rapid return of spontaneous ventilation

Treatment Patient is put on supine position If significant air leak –

re-explored.post op ventilation with pressure controlled ventilation chest tube placed under water

REFERENCES

Miller:text book of anaesthesia

Kaplan :thoracic anaesthesia

Benumof:thoracic anaesthesia