Can Peripheral Bronchopleural Fistula Demonstrated on Computed Tomography be Treated Conservatively? A Retrospective Analysis

Abstract

Purpose: Peripheral bronchopleural fistulas (BPF) are communications between a peripheral bronchus or the lung parenchyma and the pleural space. Although reported cases with peripheral BPF might have typical symptoms, we postulate that there may be BPF patients without typical symptoms who are diagnosed on computed tomography (CT) for the first time.

Materials and methods: We searched retrospectively for how frequently BPF is found on CT in cases with known or suspected empyema or hydropneumothorax. Also, we examined the clinical charts to ascertain if a diagnosis of BPF was suspected in the CT reports or clinically, and to determine the outcome of each case.

Results: Thirteen thoracic cavities of 12 patients were included in this study. Of these, BPF was suspected clinically in only 1. Mention in the CT report about the presence of BPF was found in 2 cases. An apparent finding of BPF on CT was found in 7 of 13 (53%) thoracic cavities of 6 cases. The outcomes were that 1 patient died 1 month later due to multiple organ failure, and 1 patient was discharged subsequently after CT. In the other 10 cases, there was no exacerbation of the symptom regardless of definite evidence of BPF on CT.

Conclusions: In conclusion, when there is hydropneumothorax on CT, it is important for radiologists to diligently search for findings of peripheral BPF and to document it. However, a reference about the need for a surgical approach for BPF may not be required.

FIGURE 1

Case 2: A 64-year-old woman with necrotizing pneumonia. A, CT scans obtained in a woman who had persistent pneumonia show a cavitary, round lesion (arrow) in the consolidated right middle lobe that is a probable lung abscess. B, Follow-up CT scan obtained one month later demonstrates the air-containing abscess with an open communication (arrow) between the abscess and the pleural space. In this case, the fistula was not noted in the CT report. The patient died of multiple organ failure approximately 2 months later.

FIGURE 2

Case 3: A 58-year-old man with empyema. CT scan shows multiple ectatic airways (A–D, arrows) at the periphery of the right lower lobe, communicating with a pocket of pleural air. These defects are multiple peripheral bronchopleural fistulas. In this case, the fistulas were mentioned in the CT report. The fistulas were reduced during the course of conservative treatment.

FIGURE 3

Case 9: A 77-year-old man after CT-guided radiofrequency ablation therapy for a primary lung cancer. The CT shows a large parenchymal defect (arrow) in the tumor after radiofrequency ablation therapy, with communication to the pleural space in the setting of a localized pneumothorax. A parenchymal pleural fistula was mentioned in the CT report. The fistula and pleural air disappeared 2 months later.

FIGURE 4

Case 10: A 67-year-old man after right lower lobectomy for a primary lung cancer. CT shows a hydropneumothorax secondary to an empyema due to methicillin-resistant Staphylococcus aureus. No apparent BPF is noted. Clinically, BPF was strongly suspected, but the empyema was cured by conservative medical therapy.