Affiliations: European Institute of Oncology, Milan, Italy,
JPS Hospital, Fort Worth, TX,
University Hospital AZ-VUB, Brussels, Belgium,
Correspondence to: Francesco Leo, MD, FCCP, European Institute of Oncology, Thoracic Surgery Department, Via Ripamonti 435, Milan 20100, Italy; e-mail: firstname.lastname@example.org
We read with interest the recently published review by Lois and Noppen in CHEST (December 2005)1 on bronchopleural fistula (BPF) and found it confusing. Even though the article is focused mainly on the endoscopic treatment of BPF, the authors widely discussed all of the clinical aspects of the problem.
In the proposed classification, the subgroup “nonpostoperative” does not contain BPF patients but only those with pneumothorax. BPF and pneumothorax do not share etiology, clinical presentation, diagnosis, prognosis, or treatment. They are simply different things.
The main clinical signs of BPF are not precisely outlined in the article. When the fistula is small (on the order of a few millimeters), the symptoms are cough, particularly when the patients is turned on the side of the fistula, and, as the authors stated, a delay in cavity filling after pneumonectomy. When empyema is present, infectious symptoms are dominant.
Concerning diagnosis, it is universally accepted that the “gold standard” for the diagnosis of BPF is bronchoscopy. The authors mentioned it at the end of the first paragraph in the “Diagnosis” section after methylene blue staining, bronchography, 133Xe ventilation study, CT scanning, and gas concentration scintigraphy. This message is misleading.
In the “Prognosis” section of the article, the authors mainly discussed the problem of pneumothorax in intubated patients. This is not relevant in a discussion of BPF.
Concerning the treatment of patients with BPF, there are few rules that the authors did not discuss. The vast majority of these patients had undergone pneumonectomy. The first step in treatment is bronchoscopy2 and drainage of the chest cavity. Afterward, a decision on surgical treatment is made (eg, Clagett procedure, direct repair, or thoracoscopy, depending on the dimension of the fistula and the time of onset). Moreover, in the “Treatment” section, mechanical ventilation is mentioned. This is not a therapy for patients with BPF.
The paragraphs on the endoscopic treatment of BPF (in the “Bronchoscopy” section of the article) are well-written and exhaustive. Unfortunately, BPF is a surgical problem that can sometimes be successfully treated by endoscopy to avoid performing an aggressive surgical treatment. But, it remains a surgical problem. Did a thoracic surgeon review this review?
We appreciate Dr Leo’s interest in our article and his comments. We agree that the clinical signs of bronchopleural fistula (BPF) vary pending on the size of the fistula.
Dr. Leo states that the conditions listed in our proposed classification of nonpostoperative etiologies do not cause BPF, but pneumothorax. This is not the case; as discussed in our article, necrotic lung complicating infection, chemotherapy or radiotherapy (for lung cancer), persistent spontaneous pneumothorax, inflammatory diseases, and other conditions have been associated with the appearance of BPF.1–10
We agree that the first step in treatment is bronchoscopy, as is mentioned several times in our article. Bronchoscopic exploration is important as a diagnostic and therapeutic intervention. It allows for the proper evaluation of the stump, attempts to localize the BPF as well as to exclude tuberculosis or other infectious etiologies, and, if possible, allows the introduction of sealants into the fistulous tract.11
Again, the comments of Dr. Leo and colleagues that the section on “Prognosis” is not relevant in a discussion on BPFs is erroneous. In our article, the literature pertaining to the persistence of air leak and mortality was addressed.11
We did not state that mechanical ventilation was a therapy for BPF. The section addresses the issue of how to best ventilate these patients without creating further problems or perpetuating the existence of the BPF
Drs. Leo Francesco and associates ask the question, did a surgeon review the article on bronchopleural fistulas written by Lois and Noppen1 before it was published in CHEST? The answer is yes. The article was reviewed by two surgeons who are knowledgeable in the field.
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