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A bronchopleural fistula (BPF) is a communication between the tracheobronchial tree and the pleural space. BPFs also may be classified as infectious, malignant, traumatic, iatrogenic, and idiopathic (Table 110-1). By far the most common types of BPFs are those that complicate pulmonary resections, and surgical techniques for their management were described in Chapter 72. The medical management of nonmalignant BPFs was discussed in Chapter 107. This chapter summarizes the options for the acute management of benign BPFs.

Table 110-1. Etiologies of Acute BPF

The acute surgical management of BPF depends not only on the etiology but also on the clinical presentation. In general, the main tenets of therapy are treatment of systemic infection, if present; drainage of infected fluid, if present; reexpansion of the lung; and treatment of the underlying cause, if at all possible. Specific management is discussed according to etiology.

Nonresectional Benign BPF

The most common nonresectional etiology for BPF is infection. BPF may be a complicating factor in necrotizing pneumonia or a lung abscess that ruptures into the pleural cavity. While bacterial infections are now more common, nonbacterial infections, such as Aspergillus or Mycobacterium tuberculosis, also have been reported to cause BPF. Clues to the development of a lung abscess with possible BPF include a nonresolving pneumonia that is refractory to antibiotics, fever, weight loss, and failure to thrive.1 Clinical presentation may range from a cough that is productive of infected sputum to frank sepsis from empyema. A pneumothorax may be present as well. Initial management relies on good drainage of the pleural space with a chest tube, broad-spectrum antibiotics to treat the underlying infection, and chest physiotherapy to aid drainage. Culture of the drainage fluid permits identification of the offending organism and specific treatment. Rarely, pulmonary resection is required. It should be noted that pulmonary resection for inflammatory diseases does carry a higher incidence of postresectional BPF.

Malignant BPFs generally are the result of necrosis of large tumors. These may be primary lung carcinomas or metastatic cancers such as sarcomas. Patients may experience shortness of breath as a result of a pneumothorax or possibly even tension pneumothorax. Management includes insertion of a chest tube to treat the pneumothorax. Depending on the stage and location of the tumor, resection may be an option, but usually malignant BPFs signal advanced disease. In patients with advanced disease, pleurodesis is sometimes effective.

Both penetrating and blunt chest trauma may result in a BPF. Laceration of pulmonary parenchyma and sublobar bronchi often can be managed by chest tube drainage alone. Failure to reexpand the lung after insertion of multiple chest tubes is an indication for surgery. Injury to the lobar or main ...

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