Semin Respir Crit Care Med 2001; 22(6): 675-684
DOI: 10.1055/s-2001-18804
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Persistent Air Leaks in Patients Receiving Mechanical Ventilation

Robert R. Kempainen, David J. Pierson
  • Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, Washington
Further Information

Publication History

Publication Date:
05 December 2001 (online)

ABSTRACT

The term bronchopleural fistula (BPF) can be loosely defined as persistent leakage of gas from the airways into the pleural space. A true BPF, however, is located in the central airways, whereas leaks located peripherally are better described by the term parenchymal-pleural fistula (PPF). The presence of a persistent leak in a mechanically ventilated patient is a worrisome prognostic sign independent of the precise origin, yet it is important to distinguish BPF from PPF in this population. Fundamental differences in the pathogenesis and natural history of these two entities dictate divergent approaches to management. This review compares and contrasts the evaluation and management of BPF and PPF in patients receiving mechanical ventilation, and provides an overview of the many nonsurgical interventions used to manage persistent leaks.

REFERENCES

  • 1 Wright C D, Wain J C, Mathisen D J, Grillo H C. Postpneumonectomy bronchopleural fistula after sutured bronchial closure: incidence, risk factors, and management.  J Thorac Cardiovasc Surg . 1996;  112 1367-1371
  • 2 Asamura H, Naruke T, Tsuchiya R, Goya H, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operations.  J Thorac Cardiovasc Surg . 1992;  104 1456-1464
  • 3 Al-Kattan K, Cattelani L, Goldstraw P. Bronchopleural fistula after pneumonectomy for lung cancer.  Eur J Cardio-thorac Surg . 1995;  9 479-482
  • 4 Pierson D J, Horton C A, Bates P W. Persistent bronchopleural air leak during mechanical ventilation.  Chest . 1986;  90 321-323
  • 5 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.  N Engl J Med . 2000;  342 1301-1308
  • 6 Cerfolio R J. The incidence, etiology, and prevention of postresectional bronchopleural fistula.  Sem Thorac Cardiovasc Surg . 2001;  13 3-7
  • 7 Stern E J, Sun H, Haramati L B. Peripheral bronchopleural fistulas: CT imaging features.  Am J Roentgenol . 1996;  167 117-120
  • 8 Asamura H, Kondo H, Tsuchiya R. Management of the bronchial stump in pulmonary resections: a review of 533 consecutive recent bronchial closures.  Eur J Cardio-thorac Surg . 2000;  17 106-110
  • 9 Dreyfuss D, Soler P, Basset G, Saumon G. High inflation pressure pulmonary edema: respective effects of high airway pressure, high tidal volumes, and positive end-expiratory pressure.  Am Rev Respir Dis . 1988;  137 1159-1164
  • 10 Dreyfuss D, Soler P, Saumon G. Mechanical ventilation- induced pulmonary edema: interaction with previous lung alterations.  Am J Respir Crit Care Med . 1995;  151 1568
  • 11 de Perrot M, Licker M, Robert J, Spiliopoulos A. Incidence, risk factors, and management of bronchopleural fistulae and pneumonectomy.  Scand Cardiovasc J . 1999;  33 171-174
  • 12 Yamamoto R, Tada H, Kishi A, Tojo T. Effects of preoperative chemotherapy and radiation therapy on human bronchial blood flow.  J Thorac Cardiovasc Surg . 2000;  119 939-945
  • 13 Sonobe M, Nakagawa M, Ichinose M, Ikegami N, Nagasawa N, Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer.  Eur J Cardio-Thorac Surg . 2000;  18 519-523
  • 14 Rusch V W, Capps J S, Tyler M L, Pierson D J. The performance of four pleural drainage systems in an animal model of bronchopleural fistula.  Chest . 1988;  93 859-863
  • 15 Hollaus P H, Lax F, Janakiev D. Endoscopic treatment of postoperative bronchopleural fistula: experience with 45 cases.  Ann Thorac Surg . 1998;  66 923-927
  • 16 McManigle J E, Fletcher G L, Tenholder M F. Bronchoscopy in the management of bronchopleural fistula.  Chest . 1990;  97 1235-1238
  • 17 Baumann W R, Ulmer J L, Ambrose P G, Garvey M J, Jones D T. Closure of a bronchopleural fistula using decalcified human spongiosa and a fibrin sealant.  Ann Thorac Surg . 1997;  64 230-233
  • 18 Ali S A, Hogge M, Cesani F. Localization of a bronchopleural fistula in a postpneumonectomy patient using ventilation scintigraphy.  Clin Nucl Med . 1995;  20 943
  • 19 Pierson D J. Barotrauma and bronchopleural fistula. In: Tobin MJ ed. Principles and Practice of Mechanical Ventilation New York, NY: McGraw-Hill, Inc 1994: 813-836
  • 20 Bishop M J, Benson M S, Pierson D J. Carbon dioxide excretion via bronchopleural fistulas in adult respiratory distress syndrome.  Chest . 1987;  91 400-402
  • 21 Hollaus P H, Lax F, El-Nashef B B, Hauck H H, Lucciarini P, Pridun N S. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases.  Ann Thorac Surg . 1997;  63 1391-1397
  • 22 Litmanovitch M, Joynt G M, Cooper P JF, Kraus P. Persistent bronchopleural fistula in a patient with adult respiratory distress syndrome.  Chest . 1993;  104 1901-1902
  • 23 Beaty C D, Ritz R H, Benson M S. Continuous in-line nebulizers complicate pressure support ventilation.  Chest . 1989;  96 1360-1363
  • 24 Powner D J, Cline C D, Rodman G H. Effect of chest-tube suction on gas flow through bronchopleural fistula.  Crit Care Med . 1985;  13 99-101
  • 25 Roth M D, Wright J W, Bellamy P E. Gas flow through a bronchopleural fistula.  Chest . 1988;  93 210-213
  • 26 Pruitt R F, Messick W J, Thomason M H. Respiratory alkalosis caused a assist control mechanical ventilation in a patient with a bronchopleural fistula.  J of Trauma . 1996;  40 481-482
  • 27 Zimmerman J E, Colgan D L, Mills M. Management of a bronchopleural fistula complicating therapy with positive end expiratory pressure (PEEP).  Chest . 1973;  64 526-529
  • 28 Lau K Y. Postural management of bronchopleural fistula.  Chest . 1988;  94 1122
  • 29 Downs J B, Chapman R L. Treatment of bronchopleural fistula during continuous positive pressure ventilation.  Chest . 1976;  69 363-366
  • 30 Phillips Y Y, Lonigan R M, Joyner L R. A simple technique for managing a bronchopleural fistula while maintaining positive pressure ventilation.  Crit Care Med . 1979;  7 351-353
  • 31 Gallagher T J, Smith R A, Kirby R R, Civetta J M. Intermittent inspiratory chest tube occlusion to limit bronchopleural cutaneous airleaks.  Crit Care Med . 1976;  4 328-332
  • 32 Blanch P B, Koens J C, Layon A J. A new device that allows synchronous intermittent inspiratory chest tube occlusion with any mechanical ventilator.  Chest . 1990;  97 1426-1430
  • 33 Bevelaqua F A, Kay S. A modified technique for the management of bronchopleural fistula in ventilator-dependent patients: a report of two cases.  Respir Care . 1986;  31 904-908
  • 34 Carlon G C, Kahn R C, Howland W S, Ray C, Turnbull A D. Clinical experience with high frequency jet ventilation.  Crit Care Med . 1981;  9 1-6
  • 35 Turnbull A D, Carlon G C, Howland W S, Beattie E J. High-frequency jet ventilation in major airway or pulmonary disruption.  Ann Thorac Surg . 1981;  32 468-474
  • 36 Carlon G C, Ray C, Pierri M K, Groeger J, Howland W S. High frequency jet ventilation: theoretical considerations and clinical observations.  Chest . 1982;  81 350-354
  • 37 Carlon G C, Ray C, Klain M, McCormick P M. High-frequency positive-pressure ventilation in management of a patient with bronchopleural fistula.  Anesthesiology . 1980;  50 160-162
  • 38 Campbell D, Steinmann M, Porayko L. Nitric oxide and high frequency jet ventilation in a patient with bilateral bronchopleural fistulae and ARDS.  Can J Anesth . 2000;  47 53-57
  • 39 Derderian S S, Rajagopal K R, Abbrecht P H, Bennett L L, Doblar D D, Hunt K K. High frequency positive pressure ventilation in bilateral bronchopleural fistulae.  Crit Care Med . 1982;  10 119-121
  • 40 Mortimer A J, Laurie P S, Garrett H, Kerr J H. Unilateral high frequency jet ventilation.  Intensive Care Med . 1984;  10 39-41
  • 41 Albelda S M, Hansen-Flaschen J H, Taylor E, Lanken P N, Wollman H. Evaluation of high-frequency jet ventilation in patients with bronchopleural fistulas by quantitation of the airleak.  Anesthesiology . 1985;  63 551-554
  • 42 Ritz R, Benson M, Bishop M J. Measuring gas leakage from bronchopleural fistulas during high-frequency jet ventilation.  Crit Care Med . 1984;  12 836-837
  • 43 Rubio J J, Algora-Weber A, Dominguez-de Villota E, Chamorro C, Mosquera J M. Prolonged high-frequency jet ventilation in a patient with bronchopleural fistula: an alternative mode of ventilation.  Intensive Care Med . 1986;  12 161-163
  • 44 Bishop M J, Benson M S, Sato P, Pierson D J. Comparison of high-frequency jet ventilation with conventional mechanical ventilation for bronchopleural fistula.  Anesth Analg . 1987;  66 833-838
  • 45 McGuire G P. Lung ventilation and bronchopleural fistula.  Can J Anesth . 1996;  43 1275-1276
  • 46 Parish J M, Gracey D R, Southorn P A, Pairolero P A, Wheeler J T. Differential mechanical ventilation in respiratory failure due to severe unilateral lung disease.  Mayo Clin Proc . 1984;  59 822-828
  • 47 Lohse A W, Klein O, Hermann E. Pneumatoceles and pneumothoraces complicating staphylococcal pneumonia: treatment by synchronous independent lung ventilation.  Thorax . 1993;  48 578-580
  • 48 Carvalho P, Thompson W H, Riggs R, Carvalho C, Charan N B. Management of bronchopleural fistula with a variable-resistance valve and a single ventilator.  Chest . 1997;  111 1452-1454
  • 49 Rafferty T D, Palma J, Motoyama E K, Schachter N, Ciarcia M. Management of a bronchopleural fistula with differential lung ventilation and positive end-expiratory pressure.  Respir Care . 1980;  25 654-657
  • 50 Martin W R, Siefkin A D, Allen R. Closure of bronchopleural fistula with bronchoscopic instillation of tetracycline.  Chest . 1991;  99 1040-1042
  • 51 Jaeger J M, Durbin Jr G C. Special purpose endotracheal tubes.  Respir Care . 1999;  44(6) 661-683
  • 52 Brown C R. Postpneumonectomy empyema and bronchopleural-fistula-use of prolonged endotracheal intubation: a case report.  Anesth Analg . 1973;  52 439-441
  • 53 Westcott J L, Volpe J P. Peripheral bronchopleural fistula: CT evaluation in 20 patients with pneumonia, empyema, or postoperative air leak.  Radiology . 1995;  196 175-181
  • 54 Jain R, Baijal S S, Phadke R V, Pandey C K, Saraswat V A. Endobronchial closure of a bronchopleural cutaneous fistula using angiography catheters.  Am J Roentgenol . 2000;  175 1646-1647
  • 55 Ratliff J L, Hill J D, Tucker H, Fallat R. Endobronchial control of bronchopleural fistulae.  Chest . 1977;  71 98-99
  • 56 Regal G, Sturm J A, Neumann C, Schueler S, Tscherne H. Occlusion of bronchopleural fistula after lung injury-a new treatment by bronchoscopy.  J of Trauma . 1989;  29 223-226
  • 57 Lan R S, Lee C H, Tsai Y H, Wang W J, Chang C H. Fiberoptic bronchial blockade in a small bronchopleural fistula.  Chest . 1987;  92 944-945
  • 58 Jones D P, David I. Gelfoam occlusion of peripheral bronchopleural fistulas.  Ann Thorac Surg . 1986;  42 334-335
  • 59 Salmon C J, Ponn R B, Westcott J L. Endobronchial vascular occlusion coils for control of a large parenchymal bronchopleural fistula.  Chest . 1990;  98 233-234
  • 60 Ponn R B, Dagostino R S, Stern H, Westcott J L. Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils.  Ann Thorac Surg . 1993;  56 1343-1347
  • 61 Ellis J H, Sequeira F W, Weber T R, Eigen H, Fitzgerald J F. Balloon catheter occlusion of bronchopleural fistulae.  Am J Roentgenol . 1982;  138 157-159
  • 62 McCormick B A, Wilson I H, Berrisford R G. Bronchopleural fistula complicating group A β-hemolytic streptococcal pneumonia: use of a Fogarty embolecteomy catheter for selective bronchial blockade.  Intensive Care Med . 1999;  25 535-537
  • 63 Pace R, Rankin R N, Finley R J. Detachable balloon occlusion of bronchopleural fistulae in dogs.  Invest Radiol . 1983;  18 504-506
  • 64 Hartmann W, Rausch V. New therapeutic application of the fiberoptic bronchoscope.  Chest . 1977;  71 237
  • 65 Roksvaag H, Skalleberg L, Nordberg C, Solheim K, Hoivik B. Endoscopic closure of bronchopleural fistula.  Thorax . 1983;  38 696-697
  • 66 Scappaticci E, Ardissone F, Ruffini E, Baldi S, Mancuso M. Postoperative bronchopleural fistula: endoscopic closure in 12 patients.  Ann Thorac Surg . 1994;  57 119-122
  • 67 Glover W, Chavis T V, Daniel T M, Kron I L, Spotnitz W D. Fibrin glue application through the flexible bronchoscope: closure of bronchopleural fistulas.  J Thorac Cardiovasc Surg . 1987;  93 470-472
  • 68 Jessen C, Sharma P. Use of fibrin glue in thoracic surgery.  Ann Thorac Surg . 1985;  39 521-524
  • 69 Kjaergard H K, Weis-Fogh U S, Thiis J J. Preparation of autologous fibrin glue from pericardial blood.  Ann Thorac Surg . 1993;  55 543-544
  • 70 Cohn S M, Feinstein A J, Nicholas J M. Recipe for poor man's fibrin glue.  J of Trauma . 1998;  44 907
  • 71 Dresdale A, Rose E A, Jeevanadam V, Reemtsma K, Bowman F O, Malm J R. Preparation of fibrin glue from single-donor fresh frozen plasma.  Surgery . 1985;  91 850
  • 72 Varoli F, Roviaro G, Grignani F, Vergani C, Maciocco M, Rebuffat C. Endoscopic treatment of bronchopleural fistulas.  Ann Thorac Surg . 1998;  65 807-809
  • 73 Madsen K H, Schusle S, Pederssen V M, Halkier E. Management of bronchopleural fistula following pneumonectomy.  Scand J Cardiovasc Surg . 1984;  18 263-266
  • 74 Sprung J, Krasna M J, Yun A, Thomas P, Bourke D. Treatment of a bronchopleural fistula with a Fogarty catheter and oxidized regenerated cellulose (Surgicel).  Chest . 1994;  105 1879-1881
  • 75 Wang K P, Schaeffer L, Heitmiller R, Baker R. Nd:YAG laser closure of a bronchopleural fistula.  Monaldi Arch Chest Dis . 1993;  48 301
  • 76 O'Neill P J, Flanagan H L, Mauney M C, Spotnitz W D, Daniel T M. Intrathoracic fibrin sealant application using computed tomography fluoroscopy.  Ann Thorac Surg . 2000;  70 301-302
  • 77 Kinoshita T, Miyoshi S, Katoh M. Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax.  Chest . 2000;  117 790-795
  • 78 Samuels L E, Shaw P M, Blaum Jr C L. Percutaneous technique for management of persistent airspace with prolonged air leak using fibrin glue.  Chest . 1996;  109 1653-1655
  • 79 Thistlethwaite P A, Luketich J D, Ferson P F, Keenan R J, Jamieson S W. Ablation of persistent air leaks after thoracic procedures with fibrin sealant.  Ann Thorac Surg . 1999;  67 575-577
  • 80 Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients.  Ann Thorac Surg . 1998;  65 924-926
  • 81 de la Torre M. Treatment of pneumothorax with VATS and bullectomy under local anesthesia.  Ann Thorac Surg . 1999;  68 2383
  • 82 Rivas J J, Blanco S, de la Torre M. Postsurgical pleurodesis with autologous blood in patients with persistent air leak.  Ann Thorac Surg . 2000;  70 270-272
  • 83 Robinson C L. Autologous blood for pleurodesis in recurrent and chronic spontaneous pneumothorax.  Can J Surg . 1987;  30 428-429
  • 84 Dumire R, Crabbe M M, Mappin F G, Fontenelle L J. Autologous ``blood patch'' pleurodesis for persistent pulmonary air leak.  Chest . 1992;  101 64-66
  • 85 Mallen J K, Landis J N, Frankel K M. Autologous ``blood patch'' pleurodesis for persistent pulmonary air leak.  Chest . 1993;  103 326-327
  • 86 Ando M, Yamamoto M, Kitagawa C. Autologous blood-patch pleurodesis for secondary spontaneous pneumothorax with persistent air leak.  Respir Med . 1999;  93 432-434
  • 87 Cagirici U, Sahin B, Cakan A, Kayabas H, Buduneli T. Autologous blood patch pleurodesis in spontaneous pneumothorax with persistent air leak.  Scand Cardiovasc J . 1998;  32 75-78
  • 88 Janzing H M, Derom A, Derom E, Eeckhout C, Derom F, Rosseel M T. Intrapleural quinacrine instillation for recurrent pneumothorax or persistent air leak.  Ann Thorac Surg . 1993;  55 368-371
  • 89 Chee C BE, Wang Y T, Poh S C. Dextrose pneumonitis: a complication of intrapleural instillation of 50% dextrose for pneumothorax with persistent air leak: a case report.  Singapore Med J . 1992;  33 641-642
  • 90 Almassi G H, Haasler G B. Chemical pleurodesis in the presence of persistent air leak.  Ann Thorac Surg . 1989;  47 786-787
  • 91 Chichani V. Tetracycline pleurodesis for persistent air leak.  Ann Thorac Surg . 1990;  49 166-170