Conventional versus high frequency jet ventilation with a bronchopleural fistula

A bronchopleural fistula (BPF) is an aberrant pathway through which inspired gas exits the lungs. A BPF may cause significant respiratory compromise, which in turn may result in the need of mechanical ventilation. The purpose of this study was to compare the efficacy of conventional positive pressure ventilation (CV) with high frequency jet ventilation (HFJV) using increasing increments of positive end expiratory pressure (PEEP) in the management of an induced BPF. A reproducible model of a BPF was surgically created in 10 mongrel dogs. Measurements of blood pressure (BP), cardiac output (CO), mean airway pressure (Maw), peak airway pressure (Paw), and fistula flow (FF) were carried out with the chest closed. Selective occlusion of the BPF allowed for blood gas stabilization at increased values of PEEP. Paired observations were performed at 0, 5, 10, 15, and 20 cm H2O of PEEP, while maintaining PaCO2 between 30 and 50 Torr. There was no difference in BP or CO between ventilation methods even though significantly lower Maw and Paw pressures were obtained using HFJV. While FF increased significantly with each increment of PEEP, there was no improvement in flows obtained using HFJV. This acute model of a BPF demonstrated that increasing PEEP dramatically increases FF irrespective of the method of ventilation.     

Comparison of high-frequency jet ventilation with conventional mechanical ventilation for bronchopleural fistula

In seven patients with acute respiratory failure and a bronchopleural fistula, the authors compared gas exchange and volume of gas lost via the chest tube during conventional mechanical ventilation (CV) and high-frequency jet ventilation (HFJV). After the initial comparison, patients were randomized to HFJV or CV, unless one mode of ventilation was clearly superior based on preestablished criteria. In six of the seven patients, oxygenation deteriorated after the switch from CV to HFJV. The ratio of PaCO2 to FI02 declined from 227 +/- 167 to 133 +/- 100 (mean +/- SD, P less than 0.05), and the PaCO2 increased from 47 +/- 13 to 56 +/- 18 mm Hg (P less than 0.05). The mean chest tube leak did not change significantly. Randomization of the mode of ventilation was not performed in any patient because CV was superior by a priori criteria. We conclude that when acute respiratory failure is complicated by a bronchopleural fistula, HFJV with mean airway pressures comparable to those provided during conventional ventilation does not provide satisfactory gas exchange.     

Artificial ventilation of a canine model of bronchopleural fistula

The authors studied the abnormalities of gas exchange and lung mechanics in a canine model of bronchopleural fistula during intermittent positive pressure ventilation (IPPV) and high-frequency oscillatory ventilation (HFOV). The left lower lobe bronchus was opened to atmosphere and it was determined that end expired volume was best maintained at frequencies of 45-50 breaths/min. during IPPV. Comparing alternating periods of IPPV and HFOV in six dogs (Group I) at matched airway opening pressure (Pao), we found that Pao2 decreased significantly to 68 +/- 14 mmHg and 69 +/- 24 mmHg, respectively, on opening the fistula. In a second group of six dogs (Group 2), when Pao was increased by additional bias flow into the ventilatory circuit during both IPPV and HFOV, Pao2 increased significantly to 89 +/- 12 mmHg and 87 +/- 8 mmHg, respectively. Repeating Group 2 studies after induction of oleic acid low-pressure pulmonary edema demonstrated that conventional IPPV was associated with large intrapulmonary shunts. HFOV, however, maintained gas exchange at near baseline values. For both Group 1 and Group 2, the calculated gas flow through the fistula was significantly less at all levels of airway pressure during HFOV. The authors conclude that HFOV offers advantages over conventional IPPV in the maintenance of oxygenation and in the reduction of gas leak through the fistula.     

Independent lung ventilation in the management of traumatic bronchopleural fistula

Independent lung ventilation (ILV) is a technique for managing patients with unilateral lung disease or injury who have failed conventional mechanical ventilation. A 20-year-old man sustained severe ballistic injuries to the chest and abdomen. Damage control laparotomy controlled the patient's initial hemorrhage, however, an evolving cavitary pulmonary lesion subsequently developed into a high-volume bronchopleural fistula. Progressive atelectasis of the damaged lung resulted in profound hypoxemia and hypercarbia refractory to conventional mechanical ventilation. Synchronous ILV was initiated using a double-lumen endotracheal tube and two ventilators titrated to optimize the patient's oxygenation and ventilation and minimize ventilator-induced lung injury. Intensive ILV over the next 17 days resulted in recruitment of the atelectatic right lung, resolution of the bronchopleural fistula, and significant improvement in oxygenation and pulmonary compliance. This appears to be the longest reported use of ILV for traumatic lung injury.     

The use of combined high-frequency jet ventilation and intermittent positive pressure ventilation in bilateral bronchopleural fistulae

Dissatisfaction with the results of conventional respiratory support has led to the use of high-frequency jet ventilation in desperate clinical situations with severe acute respiratory failure. We report a case of a 77 year old man with bilateral bronchopleural fistulae, who was ventilated with a combination of intermittent positive pressure ventilation and high-frequency jet ventilation. The hemodynamic and respiratory advances of this combination are discussed in an overview of the literature.     

Nitric oxide and high frequency jet ventilation in a patient with bilateral bronchopleural fistulae and ARDS

PURPOSE: To describe a method of delivering nitric oxide during high frequency jet ventilation. CLINICAL FEATURES: A 63-yr-old man underwent reduction pneumoplasty for bullous emphysema. Postoperatively, ventilation was inadequate, secondary to bilateral high output bronchopleural fistulae. High frequency jet ventilation was initiated and achieved adequate ventilation (pH>7.2). Over the following 24 hr, progressive hypoxemia (SaO2 <86%) developed along with the acute respiratory distress syndrome. Nitric oxide was delivered by continuous flow at the patient Y-connector during combined high frequency jet and conventional ventilation (two conventional low volume breaths/minute). Substantial improvement in oxygenation (FiO2 0.8 0.5, SaO2 >92%) was noted initially and was sustained over 72 hr. Subsequently, the patient was weaned to conventional ventilation without difficulty. Mechanical ventilation was discontinued on postoperative day sixteen. CONCLUSION: The simultaneous use of nitric oxide and high-frequency jet ventilation was used safely and effectively in this patient as a method of support for acute respiratory distress syndrome with co-existing large bilateral bronchopleural fistulae.     

High frequency oscillatory ventilation in the management of a high output bronchopleural fistula: a case report

PURPOSE: To describe the use of high frequency oscillatory ventilation (HFOV) in the management of a high output bronchopleural fistula (BPF). CLINICAL FEATURES: A 55-yr-old female developed a BPF after thoracotomy and decortication of an empyema. The patient deteriorated on the second postoperative day (pH 7.10 PCO2 89) requiring 100% oxygen and mechanical ventilation. After initial improvement, deterioration occurred by 24 hr with conventional positive pressure ventilation (volume or pressure limited) because of decreased pulmonary compliance and bilateral diffuse airspace disease (acute respiratory distress syndrome), persistent increased peak and plateau airway pressures, a prolonged inspired oxygen concentration greater than 0.6, and inability to apply positive end expiratory pressures because of an increased BPF leak (530 mL.breaths(-1)). HFOV was initiated and maintained for 28 days until resolution of the airspace disease and decreased leak through the BPF to 100 mL.breaths(-1). CONCLUSION: We report the successful use of HFOV in a patient with high output BPF. We suggest that HFOV is a useful technique in patients with a BPF when conventional positive pressure ventilation fails.     

Aerosol ventilation scintigraphy in the evaluation of bronchopleural fistula: a case report and literature review

Radioaerosol scanning is simple to perform and is widely used in conjunction with perfusion imaging to detect pulmonary emboli. It may also be a valuable tool for the early diagnosis of postpneumonectomy bronchopleural fistula. The authors present an illustrative case in which radioactive aerosol imaging was used to confirm a bronchopleural fistula secondary to pneumonectomy for squamous cell carcinoma.     

High frequency ventilation combined with spontaneous breathing during bronchopleural fistula repair: a case report

Purpose

We report the addition of high frequency oscillatory ventilation (HFOV), combined with spontaneous breathing under general anesthesia, during an uncommon technique to occlude a late post-pneumonectomy bronchopleural fistula.

Clinical features

A 41-year-old woman underwent an extended right pneumonectomy with chest wall resection and prosthetic reconstruction for a large adenocarcinoma of the upper lobe (T3N0M0). Her postoperative recovery was satisfactory, and she subsequently received adjuvant chemotherapy. Four months later, however, she was readmitted for investigation of confusion and pink expectorations. On cerebral magnetic resonance imaging, a frontal metastasis with surrounding edema was discovered, as well as a possible secondary lesion in the occipital lobe. In view of the comorbidities, thoracoscopy was planned as an interim measure, with the goal being to debride the fistula and to seal the prosthetic plug. During this case, a HFOV system was used to allow an addition of 2.5 L·min^?1 of minute ventilation to the patient’s spontaneous respiration, while maintaining eucapnia without increasing airway pressure.

Conclusions

With the addition of high frequency ventilation under general anesthesia in a patient with a persistent bronchopleural fistula, the PaCO₂ level was adequately controlled during the simultaneous use of fibreoptic bronchoscopy and video assisted thoracoscopy to facilitate a successful surgical repair.     

Use of a modified endobronchial tube for mechanical ventilation of patients with bronchopleural fistula.

Mechanical ventilation in patients with bronchopleural fistula after lung resection is a major problem, as it causes increase of the air-leak, complicates the healing process and makes residual lung tissue ventilation difficult. We present two cases in which the use of a modified double lumen endobronchial tube improved ventilation and eliminated the fistula air-leak. We used a right-sided double lumen sher-i-bronch tube (Sheridan Catheter Corp., USA). This method, by blocking the airflow through the fistula, may facilitate the expansion of the residual lung parenchyma. In both the patients treated with this technique, we obtained a good expansion of the residual parenchyma. Despite the procedure, the first patient died of septic shock; in the second patient, we achieved improvement of the respiratory function, the weaning from the mechanical ventilation, and thereafter, the healing of the fistula. The use of a modified double lumen sher-i-bronch tube in mechanically ventilated patients with post-resection bronchopleural fistula allows the anaesthesiologist to suction separately the two lungs and to ventilate adequately the remaining lung tissue, thus obtaining the lung reexpansion and the consequent reduction of the residual pleural space, and facilitating the healing of the fistula.