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J Thorac Cardiovasc Surg 1995;110:1141-1143
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

BRONCHOPLEURAL FISTULA AND MECHANICAL VENTILATION: A SIMPLE TECHNIQUE OF MANAGEMENT?

Grenoble, France

From the Intensive Care Unit of Cardiac Surgery, Michallon Hospital, University of Grenoble, France.

A 64-year-old man weighing 82 kg was a long-term heavy smoker who was followed up for emphysema. He was hospitalized in February 1994 for dyspnea with effort. One week later, during an exercise stress test, he had an acute ascending aortic dissection and was operated on to implant an aortic composite graft (method of Bentall). Pleural cavities were drained through two mediastinal chest tubes. Weaning from extracorporeal circulation was difficult, and prolonged inotropic support was needed.

Chest tubes were connected to suction (30 cm H₂O pressure). Continuous air bubbling in the left drainage system appeared at postoperative hour 26. Chest infection occurred on the third day, so antibiotic therapy was started. Sedation and mechanical ventilation were continued at an inspired oxygen fraction of 50% to 60%.

A chest scan on the nineteenth day showed a huge emphysematous bubble in the right upper lobe with bilateral parenchymal lesions. By the beginning of the fourth week, the patient was able to breathe with an endotracheal tube for 2 or 3 hours daily, but a right pneumothorax suddenly developed and was drained by a resident. Air leakage almost completely disappeared by the fifth week, and the patient could breathe spontaneously through his tracheostomy for a whole day.

The patient's condition deteriorated on the postoperative day 37. He was in septic shock. A high-flow right bronchopleural fistula (BPF) reestablished, causing an air leak of 55% of each tidal volume. All regimens of ventilation* were tried without satisfactory result. The drainage bottle was removed from suction because it was considered to be promoting air leak.

A few days later, the patient's general condition had been ameliorated but sedation and mechanical ventilation were maintained. The main problem was the persistance of right BPF, which caused an air leak estimated to be at least 45% of each tidal volume. The option of surgical treatment was rejected by both surgeons and anesthesiologists. On postoperative day 50 (13 days of the right BPF), a system was designed to reduce air leak and to ameliorate lung ventilation.

METHOD AND MATERIAL

A small plastic cylinder (7 cm in length) with a hermetic cap to which was attached two small-bore pieces of tubing was used to construct a valve. On the inner face of the cap, one finger of a surgical glove was fixed (in from of a balloon) on one of the two inlets leading to a piece of small-bore tubing. This tubing was connected to the ventilator circuit. The other tubing connected the inside of the cylinder to the outlet of chest-tube bottle. A small hole (5 to 7 mm in diameter) was made in the body of the cylinder. This hole served as the only outlet for air leakage, and it closed with every mechanical inspiration. This caused the balloon to inflate (Fig. 1). The system was changed daily. A fresh, aseptic system was manually prepared near the patient. This required 5 minutes of hand work.

View larger version (21K): [in this window] [in a new window]   Fig. 1. System to provide chest tube occlusion throughout inspiration during mechanical ventilation. When inflated, balloon blocks drainage. At onset of exhalation, balloon is deflated, drainage occurs, and formation of tension pneumothorax is prevented.

The result was immediate. Expired volume rose from 7.5 L/min to 13 L/min. Ventilation was maintained on synchronized intermittent mandatory ventilation. Transcutaneous oxygen saturation rose from 93% to 96%. Blood pressure and heart rate remained unchanged. One day later, the patient was on spontaneous ventilation with inspiratory assistance of 25 cm H₂O. To verify the efficacy of our system, the balloon valve was removed for 15 minutes (Fig. 2). The system proved efficacious with whatever mode of mechanical ventilation was used.

View larger version (31K): [in this window] [in a new window]   Fig. 2. Three intervals of 15 minutes each with, without, and again with the balloon valve system. Patient is on spontaneous respiration with a mechanical assistance of 25 cm H2O pressure. SaO2, Oxygen saturation; CVP, central venous pressure.

DISCUSSION

In a case of an inoperable BPF, all techniques of ventilation should be tried, ^1,2 as should a pleural drainage system. ^3-5 The technique described here seemed efficacious, but further trials are necessary for evaluation. The risk of tension pneumothorax is relatively low with the technique because any high pleural pressure is transmitted to the valve and opposes inflation of its balloon.

Footnotes

J THORAC CARDIOVASC SURG 1995;110:1141-3

*Principal regimens that were tried are as follows: intermittent positive-pressure ventilation with deep sedation and myorelaxants; synchronized intermittent mandatory ventilation; different inspiratory/expiratory time ratios; different waveforms, with or without positive end-expiratory pressure; and spontaneous respiration with mechanical assistance of pressure. A high-performance ventilator (Cesar) was used.

References

1. Pierson DJ. Persistent bronchopleural air leak during mechanical ventilation. Respir Care 1982;27:408-16.
   
2. Mayers I, Long R, Breen PH, Wood H. Artificial ventilation of a canine model of bronchopleural fistula. Anesthesiology 1986;64:739-46.[Medline]
   
3. Phillips YY, Lonigan RM, Joyner LR. A simple technique for managing a bronchopleural fistula while maintaining positive pressure ventilation. Crit Care Med 1979;7:351-3.[Medline]
   
4. Powner DJ, Grenvik A. Ventilatory management of life-threatening bronchopleural fistulae. Crit Care Med 1981;9:54-8.[Medline]
   
5. Vedrinne C, Gaussorgues P, Chazot C, Tigaud JM, Boyer F, Robert D. Traitement des fistules bronchopleurales (FBP) par le drainage en contrepression pleurale. Réanimation Soins Intensifs Médecine d'Urgence 1986;2:249.
   

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