A 63-year-old male presents to the hospital in acute respiratory distress, with high fevers and cough with purulent sputum. The patient has a history of adenocarcinoma of the lung and has underwent a right upper lobectomy 10 days ago. His vitals are:
Chest X-ray reveals a 3 cm pneumothorax in the right chest.
What is the next appropriate treatment option for this patient?
A. Initiate noninvasive positive pressure ventilation (NIPPV)Correct Answer: C
The first step in managing a bronchopleural fistula (BPF) is to insert a chest tube to allow drainage of air and fluid from the pleural space. BPF is a known complication after lung resection surgery and carries a high mortality and morbidity. BPF should be suspected in patients with a recent history of lung surgery presenting with dyspnea, chest pain, and hemodynamic instability. Once BPF is suspected, imaging (chest X-ray or CT) should be obtained to look for evidence of pneumothorax, or pneumomediastinum. Although supportive therapy such as high flow nasal cannula, initiation of broad-spectrum antibiotics, and diagnostic bronchoscopy are all warranted, the first step in managing BPF is chest tube insertion to drain air and fluid. This prevents worsening of the patient’s pneumothorax. Initiation of NIPPV should be deferred until a chest tube is inserted as it could also potentially worsen the pneumothorax.
A cardiothoracic surgery consult should then be obtained to determine if the patient is a candidate for surgical closure of the BPF. For those who are not a surgical candidate, placement of stents, angiographic coils, or other occlusive material can be considered as a treatment option.
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