#29 Pleural Disease Part 3: Hemothorax & Bronchoplueral Fistulas
On this episode we continue our discussion of pleural disease with a focus on hemothorax & management of bronchopleural fistulas. Small tube or large tube? When do you call in the reinforcements? What about endobronchial valves for persistent air leaks? Learn the answers to these questions - and so much more with Dr. Mike Sobieszczyk our expert interventionalist!
Quick Take Home Points:
Less may be more! Drainage of hemothorax is important to prevent complications but emerging evidence suggests that smaller bore chest tubes may be adequate and small hemothoraces can be observed.
Many options exist for bronchopleural fistulas (BPF) but remember that prevention is crucial: reducing driving pressure across it, wean to water seal as soon as possible. External (blood patch, pleurodesis) or internal (bronchial blocker, bronchial valves) can also be helpful.
Show Notes:
Hemothorax
Hemothorax is defined as pleural fluid Hematocrit > 50% of the serum value.
In a trauma patient, you should assume an effusion is a hemothorax until otherwise proven
It’s important to drain as much as possible to prevent long term complications like fibrothorax and trapped lung.
Very large chest tubes probably aren’t necessary even in traumatic hemothorax
There is a diminishing benefit for very large tubes (above 28 Fr) because of increased patient discomfort. Among stable patients with traumatic hemothorax, one multi-institutional trial suggested that a smaller tube may be adequate to drain blood.
Outcomes and complications were similar for smaller compared with larger tubes (14 Fr versus 28 to 32 Fr). As such, the criteria by which to select a smaller versus larger tube in the trauma population continue to evolve.
Very small hemothoraces may not require intervention at all
Literature would suggest that a retained hemotharx that is <300cc in volume on CT, or < 1.5cm pocket on US, will likely resolved with observation. Anything larger than that would benefit from further treatment:
Bronchopleural fistulas
Defintion: Persistent airleak that continues past 7 days.
An ounce of prevention is worth a pound of cure:
Reduce positive pressure if at all possible,
Attempt to get to water seal whenever able - suction can formalize the BPF so try to stop it!
If you’ve optimized the patient and they have a blowing air leak you can:
Intervene externally (blood patch - 100ccs - followed by flush, water seal, and raise the atrium to the level of the heart). Could also consider suspension talc pleurodesis.
Intervene internally (i.e. EBVs or endobronchial blood/TXA), float an endobronchial blocker
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Teran F, Prats MI, Nelson BP, et al. Focused transesophageal echocardiography during cardiac arrest resuscitation: jacc review topic of the week. J Am Coll Cardiol. 2020;76(6):745-754.
Arntfield R, Lau V, Landry Y, Priestap F, Ball I. Impact of critical care transesophageal echocardiography in medical-surgical icu patients: characteristics and results from 274 consecutive examinations. J Intensive Care Med. 2020;35(9):896-902.
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Undifferentiated Shock
Cardiac Arrest