What is a bronchopleural fistula?
A bronchopleural fistula is a small hole between the airways inside your child's lungs (the bronchi) and the space around the lungs (the pleural space). A bronchopleural fistula can form if your child has had a serious lung infection, such as severe pneumonia. The most common sign of bronchopleural fistula is having air in the pleural space (pneumothorax) or seeing bubbles after the placement of a chest tube. This happens because the bronchopleural fistula allows air to leak from the lungs into the pleural space.
If your child develops a bronchopleural fistula, the goal is to give the hole time to heal. Your child’s health-care team will make a care plan. While the treatment for pneumonia includes antibiotics, treatment for a bronchopleural fistula involves a chest tube to drain extra fluid or air and supportive care, such as making sure your child is comfortable and breathing well. The chest tube may need to stay in place for a while. How long will depend on how quickly your child’s body heals. Most children recover well, and the hole closes on its own with time and treatment.
How does this happen?
- Severe pneumonia: A serious lung infection can cause swelling and inflammation in the lung. This can damage the walls of the airways, creating a hole.
Why does pneumonia lead to these holes?
- Direct infection: Severe pneumonia can damage areas of the lung and airway wall. This can make it easier for a hole to form.
- Weaker immune system: Children who have trouble fighting infections, or who have other health problems, might be more likely to get these kinds of complications.
Signs and symptoms of a bronchopleural fistula
- Bubbling from a chest tube that does not stop.
- Breathing difficulties that continue or get worse, even while pneumonia is being treated.
- New or worsening chest pain, often on the side of the infection. This can cause discomfort when taking deep breaths.
While your child is recovering from pneumonia, you and your child's team will need to monitor them for these signs and symptoms. It is important to tell your child’s health-care team if you notice any changes or have any concerns.
How is a bronchopleural fistula diagnosed?
A few different steps are used to diagnose a bronchopleural fistula:
- Looking for clues: If a child keeps having air leaks in their chest, or if a chest tube for draining fluid is not working the way it should, then the health-care team might think there is a fistula. They will look for signs such as trouble breathing, air where it should not be or a chest tube that keeps bubbling.
- Pictures of the chest: Chest X-rays or CT scans are done to see what is happening inside the chest. They can show if there is an air leak. They can also help to find out what caused the problem.
The health-care team will explain everything and make sure your child is as comfortable as possible.
Chest tube placement
- Your child may need a chest tube placed to help their lungs heal. This tube drains extra air or fluid from around the lungs. This makes it easier to breathe and helps the infection get better. The tube goes between the ribs and connects to a container that collects the air and fluid.
- The chest tube stays in place until your child's lungs are better and there is no more extra air or fluid. This could take a few days, a few weeks or sometimes longer. The health-care team will check how your child is doing every day to see if the tube can be removed.
- At first, the tube may be attached to a wall suction. This helps to pull out air quickly. As your child gets better, the health-care team might change it to a gentler way of draining, such as using gravity drainage or a water seal. This helps them to see if the lungs are strong enough to stay expanded without help.
Supportive care
- To help your child get better, the health-care team will make sure they have support for breathing and nutrition and pain control.
Surgical assessment
- In extremely rare cases, if the chest tube is not effective, then surgery may be considered. The health-care team will discuss this option with you, though it is rarely needed. Most children recover fully, and the hole closes on its own with time and treatment.
How is a chest tube assessed for removal?
The chest tube will stay in place until your child’s lungs have improved and there is no extra air or fluid around the lungs. This may take a few days, a few weeks or sometimes longer. Your child’s health-care team will assess your child every day to decide when it is safe to remove the chest tube.
Wall suction is often used early in bronchopleural fistula care, especially when air is still leaking or the lung has not fully re-expanded. When the air leak is very small or begins to go away, your child’s health-care team may change to gravity drainage or a water seal. This helps them to see if your child is ready to have the chest tube removed.
If your child does well with gravity drainage or a water seal, and chest X-rays and clinical assessments show the lungs remain stable, the health-care team may clamp the chest tube for 2 to 3 days before it is removed. This means the chest tube is temporarily closed to see if your child’s lungs can stay expanded. Another chest X-ray will be done while the chest tube is clamped. Sometimes air or fluid builds up again. This can happen and does not mean the bronchopleural fistula will not heal. If this happens, the chest tube will be opened again, and your child will be given more time to heal. When there is no air leak, no fluid buildup and a stable chest X-ray, the team may try clamping the chest tube again before removing the tube.
Chest tube removal is usually done at the bedside by an interventional radiology nurse practitioner or fellow. Your child will get pain medication before the tube is removed. If your child is very anxious, medication to help them relax may be offered. Sedation is rarely needed. After the chest tube is removed, a tight dressing with petroleum jelly will be placed over the site. The dressing should stay in place for at least 2 days.
References
Lim, D. Y., Wang, M., Chokkappan, K., Lee, K. A., Leong, S., Ng, K. S., & Too, C. W. (2022). Percutaneous treatments for persistent bronchopleural and alveolar-pleural fistulae. Journal of Vascular and Interventional Radiology, 33(4), 410–415.e1.
Mocelin, T., Bueno Fischer, G., Danezi Piccini, J., de Oliveira Espinel, J., Feijó Andrade, C., & Bush, A. (2024). Necrotizing pneumonia in children: A review. Paediatric Respiratory Reviews, 52, 51–57.
Krenke, K., Sanocki, M., Urbankowska, E., Kraj, G., Krawiec, M., Urbankowski, T., Peradzyńska, J., & Kulus, M. (2015). Necrotizing pneumonia and its complications in children. Advances in Experimental Medicine and Biology, 857, 9–17.