Introduction: A bronchopleural fistula (BPF) refers to a sinus tract connecting the main stem, lobar, or segmental bronchus with the pleural space. This condition can pose a potentially catastrophic complication, particularly following pneumonectomy or other pulmonary resection. The morbidity associated with BPF varies, ranging from 25% to 71%, and its diagnosis and management often present challenges for physicians. BPF may arise from various causes, such as pulmonary infection or mass, necrosis, persistent spontaneous pneumothorax, malignancy-related chemotherapy or radiotherapy, and tuberculosis. Clinical, radiographic, and bronchoscopic findings that confirm an air leak from a bronchus to the pleural space are used to diagnose a BPF.

Case Presentation: This is a 73-year-old male with a history of stage IIIb lung squamous cell carcinoma undergoing chemotherapy and radiation therapy, presented with shortness of breath. CT chest revealed a pneumothorax, multiple cavitary lesions, and pneumonia. A BPF was identified. Broad-spectrum antibiotics were started, and a chest tube was inserted. After consultation with Interventional Radiology and Cardiothoracic Surgery, it was determined that limited intervention could be undertaken. Subsequently, the chest tube was removed, and the patient’s oxygenation stabilized with 4 to 6 liters of oxygen. Given the constrained options for addressing his medical condition, the patient and family opted for comfort care and hospice.

Management and Prognosis: In patients with BPF, air dissects along the bronchi and pulmonary vessels into the mediastinum and may move into the subcutaneous space of the face and neck. The fistula is usually very small (about the size of a pinhole). The incidence is around 1–4% in patients undergoing lung surgery and mortality rate ranges from 16–72%. Risk factors associated with the development of a BPF include malignancy and immunosuppressive therapy. Our case presented here, had only radioactive and chemotherapy, which could be contributing to his BPF, though the biggest risk factor remains surgical complication. The management varies according to the initial type of surgery, the size of the BPF, the overall patient condition and that of the remaining lung. Endoscopic treatment is reserved only for small fistulas associated with poor general condition.

References and Resources

1. Nagahiro, I., Aoe, M., Sano, Y., Date, H., Andou, A., & Shimizu, N. (2007). Bronchopleural fistula after lobectomy for lung cancer. Asian cardiovascular & thoracic annals, 15(1), 45–48. https://doi.org/10.1177/021849230701500110.
2. Baumann, M. H., & Sahn, S. A. (1990). Medical management and therapy of bronchopleural fistulas in the mechanically ventilated patient. Chest, 97(3), 721–728. https://doi.org/10.1378/chest.97.3.721.
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