Suspected bronchopleural fistula after lung resection
Adult after lung resection with a new or persistent air leak, a new pneumothorax or pleural infection.
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Cardiothoracic SurgeryManagement
Bronchopleural Fistula after Lung Resection
Bronchopleural Fistula after Lung Resection: Suspected bronchopleural fistula after lung resection → Recognise BPF: clinical clues → Protect the remaini...
Pathway Overview
20 steps
Algorithm Steps
20 total
01Start 02Action Recognise BPF: clinical clues
Suspect BPF when one or more of these clues is present.
- Persistent or new large air leak, or the chest drain cannot be removed
- New or enlarging pneumothorax, also after drain removal
- Fever, sepsis, purulent sputum or purulent drain fluid
- After pneumonectomy: air-fluid level falls by 2 cm or more on CXR
- Cough with fluid, worse when lying on the healthy side (operative side up)
- Early (7 days or less): sudden large leak, surgical emphysema; tension is possible
- New pneumonia in the other lung (spillage)
03Warning Protect the remaining lung and drain safely
Infected pleural fluid can spill through the fistula into the remaining lung. Call the thoracic surgeon now. Tension or respiratory failure: drain the space at once. Intubation with a large leak or spillage: keep upright and isolate the healthy lung (double-lumen or endobronchial tube) with anaesthesia.
- Sit up at least 45° and lie operative side down
- After pneumonectomy: underwater seal or balanced drainage only; no suction (mediastinal shift, collapse)
- Never clamp a bubbling chest drain: risk of tension pneumothorax
04Action Stabilise all patients: drainage, antibiotics, support
Continue this care through all later steps. Establish it before any closure when possible.
- Chest drain to empty the space and stop spillage (insert one, or fix one that does not work)
- Pleural fluid and sputum cultures, then broad-spectrum IV antibiotics
- Change antibiotics to culture results; reassess at 48-72 h
- Oxygen; clear secretions (bronchoscopy if needed)
- Ventilated: lowest effective airway pressures, aim for early extubation; large leak or spillage: isolate the healthy lung
- Nutrition support if NRS 2002 3 or more, BMI <18.5 kg/m2, albumin <30 g/L or weight loss >10%
05Action Confirm, locate and measure the fistula
CT and bronchoscopy for every patient with suspected BPF.
- CXR: new pneumothorax or change in the air-fluid level
- Thin-slice CT chest: fistula, residual space, other lung
- Bronchoscopy: inspect the stump or anastomosis; measure the defect (<5 mm, 5 mm or more, >10 mm); look for tumour at the stump
- Fistula not seen (occult or peripheral): localise it, e.g. methylene blue via the drain or balloon occlusion
- Tumour at the stump: biopsy and MDT; prefer adjustable, repeatable endoscopic options (e.g. stent) with drainage
- Bloods: WCC, CRP; blood cultures if septic
06Decision 7 days or less after surgery?
Early: 7 days or less (often mechanical stump failure). Intermediate: 8-30 days. Late: more than 30 days (often infection). Yes (early): urgent surgical review. No: control infection first.
- If Yes
07Action Early BPF (7 days or less): urgent thoracic surgical review
Likely mechanical stump or anastomotic failure. Discuss early surgical repair; plan bronchoscopic options at the same time.
- Early repair works best while the tissue is still healthy
- Re-close the stump on viable tissue and cover it with a vascularised flap
- Defect >10 mm, extensive dehiscence or rapid decline: surgery or a covered airway stent
08Decision Early BPF: fit for and suitable for surgical repair?
The thoracic surgeon decides with ICU and anaesthesia. Yes: surgical repair. No: treat by fistula size.
- If Yes
09Action Surgical repair: early BPF if fit, or when other treatment fails
Also for uncontrolled infection, necrosis or extensive dehiscence, a high-volume leak after repeated attempts, or drainage that fails.
- Debride; re-close the stump on viable tissue
- Cover with vascularised tissue: intercostal, serratus or latissimus muscle, omentum or pericardial fat
- Completion pneumonectomy only in selected fit patients: morbidity 50-60%, mortality 10-15%
- Unfit for repair, or repair fails: open window thoracostomy
10Decision After repair: infected residual space remains?
Check with imaging and the drain fluid. No: follow-up.
- If Yes
11Action Infected residual space: open window, then staged closure
Use negative-pressure (VAC) therapy only when the fistula is closed or sealed. With a large open fistula it can cause a massive air leak.
- Open window thoracostomy (Eloesser) to drain and clean the space
- VAC can speed granulation and make the space smaller
- When clean: close with a muscle or omental flap, thoracoplasty or Clagett closure
- After left upper lobectomy: open window may be unsuitable; the artery lies next to the bronchial stump (erosion risk)
12Outcome Fistula closed and space controlled
Follow up at 2-4 weeks and 3 months. Review removable devices.
If No- Path rejoins step 12Shared downstream outcome
If No13Decision Visible fistula 5 mm or larger at bronchoscopy?
The 5 mm and 10 mm limits are practical guides, not absolute cut-offs.
- If Yes
14Action 5 mm or larger: early bronchoscopic closure or surgery
Assess within 7-14 days. Over 10 mm, extensive dehiscence or rapid decline: covered stent or surgery.
- Central, stump or anastomotic defect: silicone or covered metal stent to bridge the defect
- Focal round defect: septal occluder or custom plug; add glue if needed
- Most devices are off-label: decide in the MDT and get informed consent
- Reassess within 72 h and at 7 days: bronchoscopy, imaging, drain output
- Look for device migration, granulation tissue and obstructive pneumonia
15Decision Fistula closed and infection controlled?
Not closed: air leak for 1 week or more without decrease, space not smaller at about 1 week, or purulent drainage with fever. Yes: follow-up. No: decide the next step in the MDT.
- If Yes
- Path rejoins step 12Shared downstream outcome
If No16Decision Not closed: surgery needed now?
Yes: uncontrolled infection or sepsis, necrosis, extensive dehiscence, drainage that fails, or a large leak after repeated bronchoscopic attempts. No (stable, infection controlled): bronchoscopic closure or a repeat attempt, decided in the MDT.
- If Yes
- Path rejoins step 09Shared downstream outcome
If No17Action Not closed, stable: bronchoscopic closure or repeat attempt
Only when infection is controlled and drainage is adequate. Escalate to surgery at once if the patient gets worse.
- After conservative care: sealant, one-way valve, plug or covered stent by fistula type
- After a failed device: check position and fit; repeat or change the device
- Reassess within 72 h and at 7 days, then check closure again
- Path rejoins step 15Shared downstream outcome
If No18Action Under 5 mm or not visible: conservative treatment first
Many small fistulas close with good drainage and time.
- Continue drainage, targeted antibiotics and nutrition
- Once infection is controlled: bronchoscopic sealant (e.g. fibrin glue) or one-way valve
- Peripheral fistula: find the responsible bronchus; test occlusion before a valve or plug
- Escalate if no clear improvement in 2-4 weeks, or at once if the patient gets worse
- Path rejoins step 15Shared downstream outcome
If No19Action More than 7 days (intermediate or late): control infection first
Often empyema. Control the source before closure when possible.
- Drain the space well; check drain position and patency
- Targeted antibiotics and nutrition
- Obtain repeat imaging at about 1 week
20Decision More than 7 days: infection controlled with drainage and antibiotics?
Yes: treat by fistula size. No (sepsis worsens, drainage fails or necrosis): surgical repair now.
- If Yes
- Path rejoins step 13Shared downstream outcome
If No- Path rejoins step 09Shared downstream outcome
Guideline Source
Chinese expert consensus on the diagnosis and management of bronchopleural fistula after pulmonary resection (2026 edition). J Thorac Dis 2026;18(8):947
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Evidence is low certainty: one Delphi consensus (China, 2026) and retrospective series. Decide each case with the thoracic surgeon and an MDT.
- Mortality is high: about 11-18% for BPF within 30 days of surgery in modern series; outcomes are worse with sepsis or mechanical ventilation.
- The 5 mm and 10 mm size limits and the 2-4 week time limits are practical guides, not absolute cut-offs.
- Most bronchoscopic devices (stents, septal occluders, plugs) are off-label for BPF and need an experienced centre.
Contraindicated Populations
ChildrenTraumatic, spontaneous or non-surgical bronchopleural fistulaOesophago-pleural fistula
Applicable Regions
AUUSEU
AU: No Australian guideline for BPF. Refer to a thoracic surgery unit; devices used for BPF closure are off-label.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Bronchopleural Fistula after Lung Resection?
The Bronchopleural Fistula after Lung Resection is a management clinical algorithm for Cardiothoracic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Chinese expert consensus on the diagnosis and management of bronchopleural fistula after pulmonary resection (2026 edition). J Thorac Dis 2026;18(8):947.
What guideline is the Bronchopleural Fistula after Lung Resection based on?
This algorithm is based on Chinese expert consensus on the diagnosis and management of bronchopleural fistula after pulmonary resection (2026 edition). J Thorac Dis 2026;18(8):947 (DOI: 10.21037/jtd-2026-1505).
What are the limitations of the Bronchopleural Fistula after Lung Resection?
Known limitations include: Evidence is low certainty: one Delphi consensus (China, 2026) and retrospective series. Decide each case with the thoracic surgeon and an MDT.; Mortality is high: about 11-18% for BPF within 30 days of surgery in modern series; outcomes are worse with sepsis or mechanical ventilation.; The 5 mm and 10 mm size limits and the 2-4 week time limits are practical guides, not absolute cut-offs.; Most bronchoscopic devices (stents, septal occluders, plugs) are off-label for BPF and need an experienced centre.. Individual patient factors may require deviation from these recommendations.
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