At The Bedside: Episode 4 – Bronchopleural Fistula Management in Positive Pressure Ventilation
Sep 12, 2023
auto_awesome
The podcast discusses the management of bronchopleural fistulas in positive pressure ventilation, emphasizing the importance of treating the patient rather than just the image. Various strategies such as water sealing, tube placement, and pleuridesis agents are discussed. Surgical options are considered as a last resort due to associated risks.
Understanding the components of the chest tube collection system and accurately assessing air leak severity is crucial for managing bronchopleural fistulas in positive pressure ventilation.
Less invasive options like blood patches and valve placement can effectively treat persistent bronchopleural fistulas, with success rates of around 89% and 50-90% respectively, while surgical interventions are usually considered as last resort measures.
Deep dives
Approach to Bronchopleural Fistulas on Mechanical Ventilation
The podcast episode discusses the approach to managing bronchopleural fistulas in the ICU. The speaker emphasizes the importance of familiarizing oneself with the chest tube collection system and its three chambers: the fluid collection chamber, the water seal chamber, and the suction control chamber. They highlight the significance of understanding how to set the system to water seal and describe the purpose and function of the water seal chamber. The importance of accurately assessing the severity of the air leak through a grading system is also emphasized. Furthermore, the speaker discusses the management of bronchopleural fistulas, including trying water seal, considering blood patches and valve placement, and exploring surgical options as a last resort.
Use of Blood Patches and Valve Placement
The podcast episode explains the use of blood patches and valve placement as interventions for persistent bronchopleural fistulas. The speaker discusses the technique involved in performing a blood patch, which entails inserting the patient's own blood through the chest tube to seal the air leak. They cite studies showing an approximately 89% success rate with blood patches, making it a valuable treatment option. Additionally, the speaker highlights the use of valve placement and the importance of identifying the location of the air leak through bronchoscopy. They describe how one-way valves can be placed to occlude specific airways, allowing air to escape while inhibiting its entry into the pleural space. The success rate of valve placement is noted to be around 50-90% in resolving air leaks. The use of pleurodesis agents, such as talc, is also mentioned as a treatment option.
Considerations for Upsizing Chest Tubes
The podcast episode discusses the consideration for upsizing chest tubes in the management of bronchopleural fistulas. The speaker explains that upsizing the chest tube may be necessary when the air leak persists despite initial interventions. They mention using larger bore chest tubes, such as 20 or 24 French sizes, to better manage the air leak and facilitate lung expansion. The placement of additional chest tubes in advantageous positions, such as anteriorly, may also be considered. The importance of ultrasound guidance in chest tube placement and the role of anatomical landmarks in ensuring safe insertion are emphasized. The speaker notes that patient factors, such as obesity, should be taken into account when determining the appropriate chest tube placement.
Advanced Interventions and Surgical Options
The podcast episode explores advanced interventions and surgical options for persistent bronchopleural fistulas. The speaker discusses the use of blood patches and valve placement as less invasive options. They highlight that surgical interventions, including pleurodesis and attempts to isolate the air leak, are usually considered as last resort measures due to the invasiveness and risks associated with surgery. The speaker explains that the decision to pursue advanced interventions depends on factors such as the duration and severity of the air leak and the patient's overall condition. They stress the need for careful assessment and individualized management plans for each patient.
