Bronchopleural Fistula

Case history: A 65-year-old patient with a history of cough and dyspnea underwent NCCT chest.

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Findings: The left lung collapsed with multiple cavitation; Right upper lobe shows cavitation. A left pleural space showing  air fluid level.

Diagnosis: Pulmonary kochs with bronchopleural fistula on the left side

Discussion: A bronchopleural fistula (BPF) refers to a communication between the pleural space and the bronchial tree. 

Causes:

• post-operative complication of pulmonary resection : considered the most common cause by far : with a reported incidence from 1.5 to 28% after a pulmonary resection 1.
• lung necrosis complicating infection, persistent spontaneous pneumothorax, chemotherapy or radiotherapy (for lung cancer), and tuberculosis .

Radiographic features:

On a chest radiograph, a bronchopleural fistula usually appears as an intrapleural air-pleural fluid collection, i.e. a hydropneumothorax. The fistula itself is almost never visualized directly but is implied in the proper clinical scenario. The air-fluid level typically extends to the chest wall and shows unequal linear dimensions on orthogonal views conforming to the pleural space.

CT is considered the imaging technique of choice for visualizing and characterizing bronchopleural fistulas  . CT may directly show a fistulous connection.

Radioaerosol scanning (e.g. xenon ventilation nuclear scintigraphy) has been successfully used in the evaluation of bronchopleural fistulas.

Bronchopleural fistula associated with tuberculosis usually follows trauma or a surgical procedure but can also occur spontaneously, presumably due to an open pathway between bronchus and pleura established by tuberculosis. High mortality can result from both the acute and chronic phases. The former occurs because of toxicity, spread of disease, and tension pneumothorax; the latter progresses to repeat small seedings and massive aspiration of empyema fluid. The diagnosis is based on an increasing amount of sputum production, air in the pleural space, a changing air-fluid level, and contralateral spread of pneumonic infiltration. CT can demonstrate the sites of communication between the pleural space and either one or more airways or the lung parenchyma in patients with bronchopleural fistula.

Harpreet Singh, MD
JP Scan private diagnostic center, Khanna, Punjab, India