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Correspondence |

Bronchopleural Fistula or Alveolopleural Fistula?: Not Just Semantics FREE TO VIEW

Navneet Singh, MD; Ritesh Agarwal, MD, DM
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Affiliations: Postgraduate Institute of Medical Education and Research Chandigarh, India,  Beth Israel Deaconess Medical Center Boston, MA

Correspondence to: Navneet Singh, MD, Senior Resident, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh-160012, India; e-mail: navneetchd@yahoo.com



Chest. 2006;130(6):1948-1949. doi:10.1378/chest.130.6.1948
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Published online

To the Editor:

We read with interest the article by Feller-Kopman et al1 (July 2006), who report the use of an endobronchial valve for the treatment of persistent air leak. We congratulate the authors on the novel use of the device. However, two aspects of this report merit careful attention.

The first point is the terminology used to describe air leaks, ie, the differentiation between alveolar-pleural fistula (APF) and bronchopleural fistula (BPF). An APF is a communication between the pulmonary parenchyma distal to a segmental bronchus and the pleural space, while a BPF is a communication between a main stem, lobar, or segmental bronchus and the pleural space.2This distinction is not merely an academic one but is therapeutically important because the treatment for the two types of fistula is drastically different. BPFs have significant morbidity and almost always require reoperation or some type of surgical intervention. By contrast, an APF rarely, if ever, require reoperation. Most air leaks, even after elective pulmonary resection, are APFs and not BPFs, while air leaks resulting from parenchymal necrosis are invariably APFs.3 Hence, it would have been more appropriate to use the term APF while describing the persistent air leak in this patient.

Secondly, the authors have not graded the air leak. Until very recently, there was no classification system. Presently, the air leaks are classified into four types.4 The largest and most uncommon is a continuous air leak, which is present throughout the respiratory cycle. This is seen in the patients who are receiving mechanical ventilation or have bronchopleural fistula. The second largest type is an inspiratory air leak seen almost exclusively in the patient receiving mechanical ventilation or with a sizable APF or a small BPF. The third largest leak is called an expiratory air leak, which is present only during expiration. This type of leak is commonly seen after pulmonary surgery and is usually due to APF. Finally, if a leak is present only with coughing, it is referred to as forced expiratory leak. More than 98% of air leaks after elective pulmonary surgery in patients not using ventilators are expiratory or forced expiratory leaks.,24 The other feature of air leaks is the size of the air leak determined with the help of a commercially available air leak meter in which the leak is measured on a scale from 1 to 7. This system not only allows proper distinction of air leaks but also has therapeutic implications. Studies56 have shown that water seal is superior to suction in small air leaks, but large leaks (greater than E4) require suction.

The authors have no conflicts of interest to disclose.

The author has no conflicts of interest to disclose.

Feller-Kopman, D, Bechara, R, Garland, R, et al (2006) Use of a removable endobronchial valve for the treatment of bronchopleural fistula.Chest130,273-275. [CrossRef] [PubMed]
 
Cerfolio, RJ Advances in thoracostomy tube management.Surg Clin North Am2002;82,833-848. [CrossRef] [PubMed]
 
Cerfolio, RJ Recent advances in the treatment of air leaks.Curr Opin Pulm Med2005;11,319-323. [CrossRef] [PubMed]
 
Cerfolio, RJ, Tummala, RP, Holman, WL, et al A prospective algorithm for the management of air leaks after pulmonary resection.Ann Thorac Surg1998;66,1726-1731. [CrossRef] [PubMed]
 
Cerfolio, RJ, Bass, C, Katholi, CR Prospective randomized trial compares suction versus water seal for air leaks.Ann Thorac Surg2001;71,1613-1617. [CrossRef] [PubMed]
 
Marshall, MB, Deeb, ME, Bleier, JI, et al Suction vs waterseal after pulmonary resection: a randomized prospective study.Chest2002;121,831-835. [CrossRef] [PubMed]
 
To the Editor:

I thank Drs. Singh and Agarwal for their insightful comments regarding our report of placing a removable endobronchial valve to facilitate closure of a bronchopleural fistula (BPF).1 We are in full agreement that precise terminology should be used when describing the underlying pathophysiology of persistent air leaks. Unfortunately, the accompanying video was not originally published as an on-line supplement as intended. I urge Drs. Singh and Agarwal to view the video (now available on-line), as it will be clear that our case was in fact due to a BPF and not an alveolopleural fistula. It shows the a flexible bronchoscope being passed via a rigid bronchoscope to the posterior basal segment of the left lower lobe with visualization of a second bronchoscope that was passed through the Eloesser flap into the pleural space. This is clearly at the bronchial level and not the parenchymal level, and hence qualifies as a true BPF. Our patient had a continuous leak through her Eloesser flap despite surgical closure, application of fibrin glue, and use of a latissimus dorsi muscle flap to cover the stump. In patients with complex BPFs, the use of removable endobronchial valves truly represents a novel approach to treatment. Their use may also be beneficial for persistent air leaks secondary to alveolopleural fistula refractory to other therapy.

References
Feller-Kopman, D, Bechara, R, Garland, R, et al Use of a removable endobronchial valve for the treatment of bronchopleural fistula.Chest2006;130,273-275. [CrossRef] [PubMed]
 

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References

Feller-Kopman, D, Bechara, R, Garland, R, et al (2006) Use of a removable endobronchial valve for the treatment of bronchopleural fistula.Chest130,273-275. [CrossRef] [PubMed]
 
Cerfolio, RJ Advances in thoracostomy tube management.Surg Clin North Am2002;82,833-848. [CrossRef] [PubMed]
 
Cerfolio, RJ Recent advances in the treatment of air leaks.Curr Opin Pulm Med2005;11,319-323. [CrossRef] [PubMed]
 
Cerfolio, RJ, Tummala, RP, Holman, WL, et al A prospective algorithm for the management of air leaks after pulmonary resection.Ann Thorac Surg1998;66,1726-1731. [CrossRef] [PubMed]
 
Cerfolio, RJ, Bass, C, Katholi, CR Prospective randomized trial compares suction versus water seal for air leaks.Ann Thorac Surg2001;71,1613-1617. [CrossRef] [PubMed]
 
Marshall, MB, Deeb, ME, Bleier, JI, et al Suction vs waterseal after pulmonary resection: a randomized prospective study.Chest2002;121,831-835. [CrossRef] [PubMed]
 
Feller-Kopman, D, Bechara, R, Garland, R, et al Use of a removable endobronchial valve for the treatment of bronchopleural fistula.Chest2006;130,273-275. [CrossRef] [PubMed]
 
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