Review Note
Last Update: 02/20/2025 02:55 AM
Current Deck: ACG Part 2::Thoracic SSU
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Commit #286290
SS_TS 1.13 Discuss the anaesthetic management of the following procedures:
Thorocotomy and thoroscopy for
o Bronchopleural fistula
Thorocotomy and thoroscopy for
o Bronchopleural fistula
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Commit #286290A bronchopleural fistula is a communication between the bronchial tree and pleural space. Clinically, it may be best described as a persistent air leak or a failure to re-inflate the lung despite chest tube drainage for 24 h.
- Causes:
- chest trauma
- complications of diagnostic or therapeutic procedures (e.g. thoracic surgery with a failure of suture/staple line)
- chest drains inserted into the lung parenchyma
- complications of mechanical ventilation
- Most fistulae are postoperative complications of pneumonectomy or lobectomy, but some are 2° to pneumonia, lung abscesses and empyema
- Management:
- Conservative measures:
- Large bore chest drains (multiple if necessary)
- The use of drainage system with adequate capabilities
- In mechanically ventilated patients, the goal is to maintain adequate ventilation and oxygenation while reducing the fistula flow to allow the leak to heal. This includes reducing inspiratory pressures, tidal volumes, respiratory rate, PEEP, and inspiratory times, and accepting permissive hypercapnia and lower oxygen saturations.
- Most air leaks will settle spontaneously over a few days if the patient can be weaned onto spontaneous respiration without high levels of continuous positive airways pressure (CPAP).
- The use of other modes of ventilation including high-frequency ventilation, oscillation, and differential lung ventilation through double-lumen tubes has been reported.
- Active intervention:
- For proximal leaks, fibreoptic bronchoscopy and direct application of sealants (e.g. cyanoacrylate, fibrin agents, gelform) have been tried with limited success.
- Refractory cases need surgical repair of the air leak by thoracoplasty, lung resection/stapling, pleural abrasion/decortication, or other techniques.
BPF: Features are productive cough, haemoptysis, fever, dyspnoea, SC emphysema, persistent air leak and falling fluid level in the post-pneumonectomy space on the CXR.
Pre-op:
- Check anatomy/distortion on CXR
- Resuscitate as needed
- Must have chest drain in situ prior to OT
- Invasive blood pressure monitoring prior to induction
Intra-op:
- Goal is to avoid soiling of good lung
- Rapid isolation of lung with DLT, do not ventilate until position is confirmed
- Many thoracic anaesthetists use a modified RSI and advance the DLT under direct vision with a fiberoptic bronchoscope to ensure correct placement in the bronchus contralateral to thefistula, before ventilation is commenced.
- Ideally, three anaesthetists are required, one for laryngoscopy and intubation, one to man the fiberoptic scope and one to watch the anaesthetic
- Once the tube has been confirmed in the correct bronchus by fiberoptic bronchoscopy, inflate the bronchial cuff first and ventilate directly on the bronchial port of the tube.
- The potential exists to enlarge the fistula by inappropriate placement of the DLT.
- IPPV increases gas leakage, causing loss of VT and the risk of tension pneumothorax. Minimise Paw.
Post-op:
- Plan HDU/ICU care for all but the most straightforward cases.
- Extubate as soon as possible.
Oxford handbook thoracic chapter