Bronchopleural Fistula

An 82-year-old man underwent right pneumonectomy for squamous cell carcinoma of the right lower lobe. His postoperative course was complicated by prolonged air leak from the chest tube, suggesting a bronchopleural fistula secondary to leakage from the bronchial stump. Over the ensuing 3 months, the air leak slowly decreased, but the patient was left with a nonhealing scar on the anterior thoracic cavity, as seen here.

Physical examination was unremarkable, except for the absence of breath sounds on the right side and the air leak from the nonhealing scar on the chest wall. A CT scan of the chest revealed the postpneumonectomy bronchopleural fistula (BPF) communicating with the residual right bronchial stump, along with evidence of prior thoracotomy on the right side. Surgery for closure of the fistula was considered, but systemic metastatic disease developed, and the patient died nearly 5 months after the initial surgery.

Drs Sonia Arunabh and Navin Verma of Queens, NY, write that BPF is a sinus tract between the bronchus and pleural space that results from a necrotizing infection or trauma and occurs in 5% of patients after pneumonectomy. It can cause significant morbidity, prolonged hospitalization, and death. The most common postsurgical cause of BPF is failure to obtain good bronchial closure and healing after lung resection. In addition, various factors, including diabetes mellitus, hypoalbuminemia, cirrhosis, the use of corticosteroids, and the presence of residual or recurrent carcinoma at the bronchial stump, predispose the patient to BPF.

BPF typically occurs 7 to 15 days after lung resection. Manifestations include fever and sudden cough with serosanguinous or purulent sputum or prolonged air leak from the chest tube. Bronchography or CT of the chest can be used to localize the fistula if the BPF is not clearly visible on bronchoscopy.

Drs Arunabh and Verma add that surgical intervention may be considered if conservative management with tube drainage, antibiotics, and nutritional support fails to close the fistula. Appropriate timing and correct application of current techniques are necessary to obtain optimal results, but repeated surgery is usually associated with high morbidity and mortality.