Role of computed tomography in guiding the management of peripheral bronchopleural fistula

The present study was designed to elucidate whether demonstration of a peripheral bronchopleural fistula on CT correlated with the need for surgical management. We retrospectively identified 33 patients, 24 males and nine females, mean age 38 years, with clinical diagnosis of peripheral bronchopleural fistula and whose chest CT scans and medical charts were reviewed. Each chart was reviewed to identify the cause of the peripheral bronchopleural fistula and its treatment. Treatment decisions were categorized as surgical or conservative. Each chest CT was evaluated for the cause of peripheral bronchopleural fistula as follows: bulla(e), lung abscess/necrotizing pneumonia, neoplasms, peripheral bronchiectasis, and trauma. The peripheral bronchopleural fistula was classified as visible on CT if a distinct channel between the lung or a peripheral bronchus and the pleura was seen on the lung windows. We found that CT was useful in guiding surgery by identifying and localizing the cause of the peripheral bronchopleural fistula in the 55% (18/33) of patients who required surgery. The peripheral bronchopleural fistula or its probable cause was identified in 91% (30/33) as follows: bulla(e) (n = 12), lung abscess/necrotizing pneumonia (n = 11), peripheral bronchiectasis (n = 5), malignancy (n = 1), and posttraumatic pneumatocele (n = 1). The peripheral bronchopleural fistula was right-sided in 24, left-sided in nine, and was visible on CT in 36% (12/33). Among the patients with bullae, 58% (7/12) required surgery; however, the peripheral bronchopleural fistula was visible on CT in only 8% (1/12). Among the 21 patients without bulla(e), the peripheral bronchopleural fistula was visible on CT in 52% (11/21). When the fistula was visible in this subgroup, 73% (8/11) required surgery compared with 30% (3/10) in whom the fistula was not visible (p = NS; Fisher exact). In conclusion, CT was useful in guiding surgery by identifying and localizing the peripheral bronchopleural fistula or its probable cause. Peripheral bronchopleural fistulas caused by bulla(e) were less likely to be visible on CT (p < 0.05). Excluding patients with bulla(e), our data suggest a trend toward the need for surgical management for patients in whom the peripheral bronchopleural fistula was visible on CT.