Introduction
Broncho pleural fistula (BPF) is an abnormal communication between pleural cavity and lobar or segmental bronchi. Most commonly occurs after lung surgeries.[1] Incidence of BPF is 0.5% post lobectomy and up to 20% post pneumonectomy.[23] Other causes include lung abscess, trauma, and radiation therapy.[1] Lobectomy and BPF are well-established risk factors for perioperative respiratory complications. Published data to guide perioperative management of such cases especially for abdominal surgeries are scarce.
Case History
A 51-year-old 50-kg gentleman status post lobectomy with BPF was posted for laparoscopic cholecystectomy in view of symptomatic gallstones. The patient had undergone right upper lobectomy eight years ago in view of aspergilloma with a previous history of chronic exposure to smoke. The patient also gives a history of chronic cough and episodes of breathlessness for which he received treatment. Preoperative evaluation showed a scar on the lateral side of the right chest wall extending posteriorly and features of right lung volume loss with supraclavicular hollowing, tracheal deviation, and thoracic scoliosis toward right, reduced breath sounds on right upper zone with similar findings on chest X-ray [Figure 1]. Patient's room air saturation was 98% with a respiratory rate of 20/minute which was regular and adequate in depth. Preoperative computed tomography scan [Figure 2a and 2b] showed right side volume loss with ipsilateral mediastinal shift and BPF. Spirometry was suggestive of obstructive pattern with FEV1/FVC of 0.69 (82%). Electrocardiogram, echocardiography, and arterial blood gas were normal. Preoperatively patient was started on incentive spirometry, salbutamol, and ipratropium bromide nebulization. Cardiothoracic surgeons were informed beforehand regarding intercostal drainage tube insertion in case pneumothorax occurs. Difficult airway cart was kept ready. Standard American Society of Anesthesiologists monitors were attached. Patient was preoxygenated and 3 mcg/kg of fentanyl was given to blunt the response on intubation. Rapid sequence intubation was done with propofol and succinylcholine using C-Mac. Patient was put on pressure-controlled ventilation with minimum pressures such that tidal volume of 6 ml/kg body weight was delivered so as to maintain ETCO2 of 35-45 mm of Hg. Minimal positive end expiratory pressure (PEEP) of 3 cm H2O was applied. An arterial cannula was inserted to facilitate arterial gas sampling. Peak airway pressures, EtCO2, tidal volume, and SpO2 were carefully monitored and any signs of pneumothorax were watched for. Intraoperative pain was managed with intravenous (IV) opioids and nonsteroidal anti-inflammatory drugs. Surgery was later converted to open surgery; hence, ultrasound-guided right-sided ESP block was given at T7 level with 20 ml of 0.25% levobupivacaine toward the end for postoperative analgesia. Surgery was uneventful with minimum blood loss. Patient extubated on table and shifted to postoperative intensive care unit. Postoperative chest X-ray did not show any new changes and arterial blood gas was normal.
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Figure 1: Showing preoperative chest X-ray image
Figure 2: (a and b) Preoperative CT image showing Broncho pleural fistula
Discussion
Management of patients with BPF is tricky as positive pressure ventilation can be ineffective because of loss of tidal volume and the escaping air can lead to pneumothorax. A laparoscopic approach is associated with less postoperative respiratory compromise than open cholecystectomy[4] but relatively contraindicated due to undesirable effect of pneumoperitoneum on respiratory function particularly in such patients. In case of open procedure, postoperative analgesia should be adequate for faster recovery because postoperative pain can further hamper the respiration of such patients. This patient was posted for laparoscopy but converted to open procedure. It is a challenging situation as we had to take care of challenges of both laparoscopic procedures and open surgery.
Newington and Ismail[5] reported a case of laparoscopic cholecystectomy post pneumonectomy. Cisatracurium was used as a muscle relaxant and intubation was done using Mc Garth videolaryngoscope.
For another reported case, they have used combined spinal epidural anesthesia and sedation with midazolam and supplemental oxygen with Hudson mask. But this procedure took around 45 minutes only.[6]
Anticipating the longer duration of the procedure and patient comfort, we preferred general anesthesia with controlled ventilation than sole regional anesthesia. Presence of scoliosis and laparoscopic procedure further strengthened the decision for general anesthesia. Although we ruled out active infection or empyema of lung, lung isolation techniques were not required.
In anticipation of difficult and hyper-reactive airway, direct laryngoscopy was not attempted. We went ahead with C-Mac–guided intubation to avoid multiple attempts and for smooth intubation. Although air leak can occur through the fistula, it is important to maintain adequate ventilation and oxygenation. Patient was ventilated with minimum pressures and PEEP of 3 cm H2O delivering tidal volume of 300 mL to avoid iatrogenic pneumothorax. Thorough monitoring of vitals, EtCO2, and peak airway pressure is important to promptly identify any complications and to intervene on time.
IV analgesics were used initially for intraoperative analgesia but when converted to open surgery, analgesia was a major concern as an extensive incision in upper abdominal surgery can hamper the respiration postoperatively. Multimodal analgesia with ultrasound-guided right-sided ESP block at T7 level with 20 ml of 0.25% levobupivacaine and IV analgesics were our choice for postoperative analgesia.
Patient was extubated uneventfully and shifted to postoperative intensive care unit once fully awake. Postoperative chest X-ray was done to rule out pneumothorax. Adequate IV analgesics and postoperative incentive spirometry were continued.
Conclusion
Management of such cases should start preoperatively. Patient should be counselled regarding anesthetic care, modes of analgesia, and perioperative respiratory complication. Difficult airway and pneumothorax should be anticipated. Preparedness, prompt monitoring, early identification of complications, and immediate intervention are required. Analgesia should also be a concern perioperatively.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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3. Fuso L, Varone F, Nachira D, Leli I, Salimbene I, Congedo MT, et al Incidence and management of post-lobectomy and pneumonectomy bronchopleural fistula Lung. 2016;194:299–305
4. Joris JLMiller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Young WL. Anesthesia for laparoscopic surgery Miller's Anesthesia. 20107th ed Philadelphia, PA, USA Churchill Livingstone:21–95
5. Newington DF, Ismail S. Laparoscopic cholecystectomy in a patient with previous pneumonectomy: A case report and discussion of anaesthetic considerations Case Rep Anesthesiol. 2014;2014:582078
6. Yi JW, Choi SE, Chung JY. Laparoscopic cholecystectomy performed under regional anesthesia in patient who had undergone pneumonectomy: A case report Korean J Anesthesiol. 2009;56:330–3
