We present two chest x-rays that were taken 8 h apart. The first one (A) depicts a right (R)-sided pneumothorax with two large bore (32-French) chest tubes and a smaller (22-French) chest tube. The pneumothorax was unable to be drained with the three chest tubes due to a bronchopleural fistula because tidal volumes escaped through the fistula. The second image (B), taken after placement of a bronchial blocker at the level of the right lower segmental bronchus, depicts a consolidation of the right lower lobe and the resolution of the bronchopleural fistula with reexpansion of the lungs. The bronchial blocker was placed under direct bronchoscopic guidance with the cuff well beyond the takeoff of the right upper lobe bronchus. This patient was intubated, sedated, and chemically paralyzed due to severe respiratory failure.
A bronchopleural fistula is a direct communication between any segment of the bronchial tree and the pleural cavity. Common causes are surgery, chest trauma, cancer, and rarely infectious. Initial management is conservative with ventilators set at low airway pressures and spontaneous ventilation when possible.1 If this is insufficient, invasive techniques including the surgical resection of the fistulous segment should be considered. If the patient is too unstable to go to the operating room, bronchoscopic techniques for occluding the fistula with a stent, coils, Amplatzer device, and occlusive materials may be used.2,3 A properly placed bronchial blocker, by an anesthesiologist or intensivist experienced in lung isolation, can provide temporary occlusion of the fistula; this may permit healing of the fistula, or maintain stability until surgical repair is undertaken.
The authors declare no competing interests.