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Ann Thorac Surg 2003;75:1662-1664
© 2003 The Society of Thoracic Surgeons

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How to do it

A new method for detection of post-pneumonectomy broncho-pleural fistulas

^a Unité de Chirurgie ThoraciqueAP-HP, Paris, France
^b Unité de Reanimation Chirurgicale Hôtel-Dieu, Paris, France

Accepted for publication October 14, 2002.

^* Address reprint requests to Dr Alifano, Chirurgia Toracica, Ospedale Bellaria, Via Altura 3, 40139 Bologna, Italy
e-mail: marcoalifano{at}yahoo.com

	Abstract

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Broncho-pleural fistula is a relatively rare but life-threatening complication of pneumonectomy. Early detection of this complication is crucial for optimal treatment. We describe a simple technique to detect postpneumonectomy broncho-pleural fistula by measuring concentrations of O₂ and N₂O in the pneumonectomy cavity at baseline and after allowing patients to breath gas mixtures enriched with O₂, N₂O, or both. The technique was used in 22 patients. In 20 control patients the test was carried out 48 hours after pneumonectomy. Both the O₂ and the N₂O test were negative in all cases. However, in 2 patients with broncho-pleural fistula both the O₂ and the N₂O tests were positive.

	Introduction

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Broncho-pleural fistula (BPF) is a relatively rare complication of pneumonectomy, occurring in 2% to 6% of cases [1, 2]. It is a life-threatening complication, with high mortality rates [1, 2]. Broncho-pleural fistulas often require complex, multistep management [1–3]. Early detection of this complication is crucial for optimal treatment of patients [1–3]. Fiberoptic bronchoscopy plays a fundamental role by allowing visualization of the fistula in most cases, as well as evaluation of the importance of the defect [1]. However its sensitivity is not fully reliable, and the diagnosis sometimes remains doubtful despite repeated bronchoscopic evaluation [1, 4].

We describe a simple technique to detect postpneumonectomy BPF by measuring concentrations of O₂, N₂O, or both in the pneumonectomy cavity at baseline and after allowing patients to breathe gas mixtures enriched with O₂ or N₂O. We recently reported the usefulness of this technique in detecting a BPF in a patient with repeated negative bronchoscopies [5]; only data about N₂O measurements were analyzed in this patient [5]. In the present paper we report details of our technique and provide preliminary results obtained in 22 patients.

	Technique

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The technique is carried out in the intensive care unit. Standard patient monitoring is used. There is no need for general anesthesia. Sampling of gas from the postpneumonectomy cavity is necessary for this technique, so it is preferably carried out in patients with a chest drain. In the absence of a chest drain, insertion of a small 12-Ch pleuro-catheter on the second intercostal space 1 cm laterally to the medioclavicular line is necessary. The drain (or the pleuro-catheter) is connected with a chest drainage unit (Pleur-evac) through a Y-shaped connector. At the remaining branch of the Y-shaped connector the sterile plastic tube of an anesthetic gas analyzer (Capnomac Ultima; Datex, Helsinki, Finland) is connected. Monitoring of gas concentrations (O₂ and N₂O) is started while the patient is breathing room air. In these conditions, the concentration of O₂ is measured as less than 21%, and N₂O is not detected. The patient is subsequently asked to breathe through a high-concentration O₂ mask (fraction of inspired O₂ = 90%). In the absence of BPF no increase in O₂ concentration is registered in the following 2 minutes. If a BPF is present, O₂ concentration will quickly increase: levels of approximately 40% are reached within half a minute. The rapidity of changes in O₂ concentration is related to the size of the fistula.

The results of the O₂ test are subsequently confirmed by an N₂O test. The patient is invited to breathe a mixture of N₂O (50%) and O₂ (50%). If no BPF is present, the absence of N₂O will be observed; conversely, in the presence of a BPF, N₂O concentration will quickly increase, reaching levels of 30% to 40% after approximately half a minute. The entire test is performed in less than 5 minutes. Similar to the O₂ test, the rapidity of changes in N₂O concentrations is related to the size of the fistula.

In ventilated patients the O₂ test can be performed only if the patient does not need ventilation with 100% oxygen. The test is commenced while the patient is breathing less than 60% oxygen. The O₂ concentration is subsequently increased to 100%, and increases in O₂ levels in air sampled from the postpneumonectomy space are observed. The N₂O test can be performed according to the same protocol, by adding N₂O to the gas mixture of the mechanical ventilation device.

We have performed the test in 22 patients so far. The study was carried out according to the recommendations outlined in the Declaration of Helsinki, and all the patients gave their informed consent.

In 20 control patients the test was carried out 48 hours after pneumonectomy immediately before chest tube removal. Both the O₂ and the N₂O tests were negative in all cases. In these patients administration of N₂O also served as an analgesic before tube removal, and no intravenous analgesia (as frequently used in our department for chest drain removal) was employed. None of these patients developed a BPF later in the postoperative period.

In 2 patients with BPF both the O₂ and the N₂O tests were positive. In one of them, bronchoscopy showed a BPF on the 12th postoperative day. The O₂ and the N₂O tests were performed on the same day, and results were positive as well. In the other patients both the O₂ and the N₂O tests were positive on the third postoperative day and bronchoscopy showed no BPF. Both the bronchoscopy and the breath test were repeated on the fourth postoperative day, and both were positive. Bronchoscopy showed a small fistula involving one third of the bronchial stump suture.

	Comment

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Despite continuous efforts to prevent postpneumonectomy BPF, it continues to be a frequent challenge for thoracic surgeons. Broncho-pleural fistula invariably causes contamination of pleural space, with development of empyema [1]. Conversely, it is well known that empyema is not necessarily accompanied by a BPF [1]. Although in most cases diagnosis of empyema with BPF is evident on the basis of clinical, laboratory, and endoscopic findings [1, 6], in some instances diagnosis remains in question despite repeated invasive studies [1, 4], mainly repeated fiberoptic bronchoscopies. In patients with an established diagnosis of postpneumonectomy empyema, a BPF should be accurately searched for, in order to optimally treat these patients [1, 4]. Diagnostic sensitivity of bronchoscopy can be enhanced by endobronchial instillation of methylene blue dye followed by searching for appearance of the dye in the pleural fluid; however, these maneuvers also are not absolutely sensitive. Some reports suggested the use of ventilation scintigraphy for diagnosis of postpneumonectomy BPF [4, 7]. In the experience of Raja and associates [4], scintigraphy with ⁹⁹Tc-diethylene triamine penta-acetic acid (DTPA) aerosols provided poor results, whereas the use of ¹³³Xe allowed good but not absolute sensitivity. Scintigraphy studies require transport of patients to the Nuclear Medicine Department, which can be difficult or hazardous in critically ill patients. Furthermore ¹³³Xe is not the standard ventilation agent in most nuclear medicine departments.

The technique we report is easy and rapid; furthermore, it can be performed at bedside. If a chest drain is already in place its invasiveness is remarkably low; otherwise a small pleuro-catheter must be inserted. However, it should be considered that when there is doubt concerning the possible presence of a BPF or empyema, sampling of pleural fluid for bacteriologic studies is generally performed, so the positioning of the pleuro-catheter would be only slightly more invasive than a thoracocenthesis.

In our preliminary experience, there were no false-positive results among the 20 control subjects, whereas both the O₂ and the N₂O tests were positive in the 2 patients with BPFs. In one of them the tests were positive but the initial bronchoscopy showed no BPF, thus proving that in some cases the test would be useful for early recognition of the BPF. We hypothesize that in this patient the initial fiberoptic bronchoscopy failed to reveal the fistula because its caliber was not sufficiently large to be visualized while being sufficiently large to allow the passage of O₂ and N₂O from the airways to the pleura. An increase in the size of the fistula probably occurred in the following hours, thus permitting visualization of the fistula at subsequent fiberoptic bronchoscopy. Early detection of a BPF (even with 1-day advance) can be clinically relevant in order to prevent the life-threatening complications of the condition.

The small number of patients evaluated in the present study (especially those with BPF) does not allow us to draw any conclusion about the exact diagnostic accuracy of the test. We think that the N₂O test would guarantee both sensitivity and specificity, because of its complete absence at baseline in the postpneumonectomy space. The rapidity of its increase (within few seconds) in the space should be considered an index of BPF size; in particular, modest but rapid changes in gas concentrations would signify the presence of small BPF (perhaps not identifiable by the O₂ test). The interpretation of the O₂ test would be relatively easy in patients not requiring supplemental oxygen at baseline, but its interpretation probably would be much more difficult in patients requiring oxygen at baseline. The test should be interpreted carefully if a multiloculated pleural effusion is suspected. In this case, a possible BPF could not communicate directly with the pleural space sampled by the chest needle or tube, thus rendering the results of the test difficult to interpret.

We used a combined O₂ and N₂O test to detect BPFs. A similar O₂ test has been used in an animal model by Firmin and colleagues [8]. In their study, sampling of air from the postpneumonectomy cavity was done by thoracentesis, and a blood gas analyzer was used for gas analysis. They also measured levels of CO₂, but results were inconsistent. The use of N₂O was not advocated [8].

We think that our technique is probably useful in the treatment of patients with suspected postpneumonectomy BPF. As sensitivity and specificity of the method have not yet been assessed, results of the test cannot be currently used for clinical decision-making. In particular, positive results in a patient with no clinical, laboratory, or endoscopic suspicion of BPF should not lead to aggressive management. Studies on larger series of patients to confirm the usefulness of our technique and to show satisfactory diagnostic accuracy will be necessary before it can be used for clinical decision-making.

	References

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1. In: Shields T.W., ed. General thoracic surgery. Baltimore: William and Wilkins, 1994:694-700.
2. Asamura H., Naruke T., Tsuchiya R., Goya T., Kondo H., Suemasu K. Bronchopleural fistulas associated with lung cancer operations. Univariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456-1464.[Abstract]
3. Regnard J.F., Alifano M., Puyo P., Fares E., Magdeleinat P., Levasseur P. Open window thoracostomy followed by intrathoracic flap transposition in the treatment of empyema complicating pulmonary resection. J Thorac Cardiovasc Surg 2000;120:270-275.[Abstract/Free Full Text]
4. Pigula F.A., Keenan R.J., Naunheim K.S., Ferson P.F., Landrenau R.J. Diagnosis of postpneumonectomy bronchopleural fistula using ventilation scintigraphy. Ann Thorac Surg 1995;60:1812-1814.[Abstract/Free Full Text]
5. Mulot A., Sepulveda S., Haberer J.P., Alifano M. Diagnosis of postpneumonectomy bronchopleural fistula using inhalation of oxygen or nitrous oxide. Anesth Analg 2002;95:1122-1123.[Free Full Text]
6. Icard P., Fleury J.P., Regnard J.F., et al. Utility of C-reactive protein measurements for empyema diagnosis after pneumonectomy. Ann Thorac Surg 1994;57:933-936.[Abstract]
7. Raja S., Rice T.W., Neumann D.R., et al. Scintigraphic detection of post-pneumonectomy bronchopleural fistulae. Eur J Nucl Med 1999;26:215-219.[Medline]
8. Firmin R.K., Turley K., Jacobs S., Ebert P.A. Changes in the respiratory gas tension of a pneumonectomy space and their application to the diagnosis of bronchopleural fistula. Thorac Cardiovasc Surg 1985;33:173-175.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jean-François Regnard Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Alifano, M. Articles by Regnard, J.-F. Search for Related Content PubMed PubMed Citation Articles by Alifano, M. Articles by Regnard, J.-F. Related Collections Lung - cancer Lung - other