Diagnosis

The diagnosis of postpneumonectomy bronchopleural fistula can be very difficult if only a pinhole fistula exists, or it can be very easy if a large bronchopleural fistula occurs with expectoration of copious amounts of serosanguineous fluid. Bronchopleural fistulae that occur early postoperatively do not usually present with infection but rather dyspnea and cough. Aspiration of even small amounts of pleural fluid into the remaining lung can cause an almost continuous irritative cough and can lead to severe respiratory distress and adult respiratory distress syndrome (ARDS). Expectoration of large amounts of brown fluid after a pneumonectomy is rare, but is pathognomonic of a bronchopleural fistula. With an early bronchopleural fistula, patients often have low-grade fever, elevated heart rate and respiratory rate, and leukocytosis. Later presentations of postpneumonectomy empyema are often those of indolent infection. Fatigue, weight loss, dull deep chest discomfort, poor appetite, cough, low-grade fever, and night sweats are seen. A high index of suspicion is necessary to make the diagnosis, especially in the very late postoperative period.

The classic radiographic finding is lowering of the fluid level in the hemithorax (Figures 43-3A,B). Caution must be used in interpreting early postoperative films that are done portably, and therefore, the degree of uprightness and location of fluid level may vary. Ventilation scan may be useful in diagnosing occult bronchopleural fistulae by observing xenon gas in the operated hemithorax.18 Computed tomography (CT) scans of the chest can be very helpful, especially in patients presenting late (Figure 43-4). Despite an opacified hemithorax by plain radiography, a CT scan can demonstrate air around the stump, which suggests bronchopleural fistula. The amount of residual fluid can be ascertained, the length and position of the bronchus can be delineated, the status of the remaining lung can be examined, and the possibility of locoregional recurrence of neoplasm can be documented.

Thoracentesis of the pneumonectomy space can be readily performed if an occult empyema is suspected. Careful sterile aspiration is necessary in order not to infect the space if it is indeed sterile. Patients diagnosed late have thickened pleura and markedly elevated hemidiaphragms, making thoracentesis more difficult. Ultrasound guidance and long needles are often helpful. Bronchoscopy is always an important step in thorough evaluation of a patient for possible bronchopleural fistula. Bronchoscopy can be performed in the early postoperative patient under local anesthesia with proper sedation and monitoring. Valuable information can be gained, such as the state of the bronchial closure, and presence of space fluid and infected secretions in the remaining lung. Watching a patient cough under local anesthesia while exam-

figure 43-3 A, Chest radiograph, 5 days after right pneumonectomy, with typical high air-fluid level. B, Chest radiograph of the same patient, 1 day later after cough and dyspnea were reported by the patient. Notice the drop in the air-fluid level. Subsequent investigation demonstrated a very small bronchopleural fistula.

figure 43-3 A, Chest radiograph, 5 days after right pneumonectomy, with typical high air-fluid level. B, Chest radiograph of the same patient, 1 day later after cough and dyspnea were reported by the patient. Notice the drop in the air-fluid level. Subsequent investigation demonstrated a very small bronchopleural fistula.

figure 43-4 Computed tomography (CT) scan of the chest of a patient, 6 months after right pneumonectomy complicated by a bronchopleural fistula. The empyema space is drained by a large bore catheter. Notice the markedly thickened pleura. The bronchial stump is widely dehisced.

ining the stump may help to diagnose occult fistulae. The absence of a fistula at bronchoscopy does not eliminate the possibility of a pinhole fistula.

The differential diagnosis of an early postoperative postpneumonectomy bronchopleural fistula is fairly broad and includes pneumonia, ARDS, fluid overload, pulmonary embolism, myocardial infarction, and postpneumonectomy pulmonary edema.

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