Bronchopleural fistula with empyema after lobectomy71-year-old man, 56 kg, three weeks after right lower lobectomy

The patient

The examiner asks

Answer aloud, then press Show.

1. Consider

   What are your concerns?

   Show the answerHide the answer

   • A 71-year-old with a bronchopleural fistula, empyema and sepsis, for urgent rethoracotomy and repair. Patient
   • At 71, septic and 7 kg lighter, he has little reserve; I record his baseline cognition for delirium.
   • Air leak, fever and pus after lobectomy point to a fistula. Disease
   • Three risks: pus soiling his left lung, tension pneumothorax, and breaths lost through the fistula.
   • His leak bubbles continuously, so the fistula is large.

2. Prepare

   How do you prepare him?

   Show the answerHide the answer

   • Sepsis first: antibiotics within the hour, cultures, and crystalloid at 30 mL/kg within three hours. Disease
   • Noradrenaline at 0.05–0.5 mcg/kg/min if he stays hypotensive after fluid; arterial line before induction.
   • His drain stays in and open; it protects him from tension pneumothorax under positive pressure.
   • No thoracic epidural while he's septic; paravertebral by the surgeon or systemic analgesia instead.
   • He sits up, leaning to the right, so pus stays in the infected side. Airway

3. Plan

   How will you secure his airway?

   Show the answerHide the answer

   • Lung isolation before any positive pressure or turning; that is the rule here. Airway
   • Left-sided double-lumen tube: it seals the healthy left lung away from the right stump.
   • Safest is awake fibreoptic placement, if he can cooperate with topical anaesthesia.
   • Otherwise a gas or titrated induction, keeping him breathing until the left lumen is sealed.
   • Bronchoscope confirms the tube position, then again after he is turned.
   • Small breaths at low airway pressure to the left lung once isolated. Disease

4. Crisis

   During laryngoscopy he coughs up pus; SpO2 falls to 80%, BP 88/50. What do you do?

   Show the answerHide the answer

   • Pus is soiling his left lung: stay head-up, suction the airway, 100% oxygen. Crisis
   • Place the left double-lumen tube now and inflate the bronchial cuff to seal the left lung.
   • Suction down the left lumen, then bronchoscopic toilet and position check.
   • Ventilate only the left lung, gently; the right lumen stays open to drain.
   • No turning until the left lung is clean and isolation is proven.
   • Expect pneumonitis in the left lung; ICU ventilation if his gas exchange stays poor. After surgery

5. Crisis

   Once he is turned, the ventilator delivers 450 mL but only 150 mL returns; SpO2 85%. What do you do?

   Show the answerHide the answer

   • Two thirds of each breath is leaving through the fistula: bronchoscope first to check the tube. Crisis
   • Turning can shift the tube; I reposition it so only the left lung is ventilated.
   • Small breaths and low pressures; I accept a higher CO2 rather than force the leak.
   • Never clamp his drain: a blocked drain turns this leak into a tension pneumothorax.
   • Still failing: high-frequency ventilation lowers peak pressure and may cut the fistula leak.
   • Extubate early after repair to spare the stump; otherwise ICU, then early extubation. After surgery