Bronchopleural fistula

Last revised by Dr Raymond Chieng on 04 Aug 2022

Bronchopleural fistulas are communications between the bronchial tree and the pleural space.  

A bronchopleural fistula is usually diagnosed at 1 week to 3 months post lobectomy or pneumonectomy, most commonly between 8 to 12 days post operation 12.

A central bronchopleural fistula is usually suspected in the early postoeprative period. It can be diagnosed easily by bronchoscopy or after a large air leak 12.

A peripheral bronchopleural fistula can be suspected when there is an air leak, prolonged pneumothorax with air-fluid level within pleural effusion or empyema, history of needle or drainage tube insertion into the thorax, presence of gas-producing bacteria or aspiration pneumonia due to backflow of pus from empyema into the bronchial tree 9.

They are usually divided as 2:

  • central: when the fistula involves the trachea or a lobar bronchus
  • peripheral: when a distal airway, either segmental bronchi or the lung parenchyma, communicates to the pleural space

On chest radiography, the features that may be seen include:

  • steady increase in intrapleural air
  • appearance of a new intrapleural gas-pleural fluid collection - i.e. a hydropneumothorax. The gas-fluid level typically extends to the chest wall and shows unequal linear dimensions on orthogonal views conforming to the pleural space
  • changes in an already present gas-fluid level
  • development of tension pneumothorax
  • a drop in the gas-fluid level exceeding 2 cm (if the patient has no chest tube in place)

CT is considered the imaging technique of choice for visualizing and characterizing bronchopleural fistulae 2. CT may show:

Radioaerosol scanning (e.g. xenon ventilation nuclear scintigraphy) has been successfully used in the evaluation of bronchopleural fistulas 5-7. A variety of radioactive tracers may be used, including:

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Cases and figures

  • Case 1: plain film
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  • Case 1: CT
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  •  Case 2: plain film
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  • Case 3
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  • Case 4
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  • Case 5: following Clagett thoracotomy
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