Bronchoscopy-Guided Placement of Petrolatum Gauze For Closure of Peripheral Bronchopleural Fistula in Humans

Summary

This protocol describes bronchoscopy-guided petrolatum gauze implantation as a minimally invasive, cost-effective endobronchial occlusion method to close peripheral bronchopleural fistulas in patients (≤5 mm) who are not candidates for surgical repair.

Abstract

Bronchopleural fistula (BPF), defined as a pathological communication between the bronchial airways and the pleural space, carries high mortality (18%–50%) due to complications like infection and respiratory failure. Current treatments, including conservative management and invasive surgery, face limitations such as variable efficacy, high trauma, and inapplicability to high-risk patients. An innovative bronchoscopy-guided petrolatum gauze occlusion protocol provides a minimally invasive, cost-effective solution for patients with small to medium-sized bronchopleural fistulas (≤5 mm) who are not candidates for surgery. Key steps included precise fistula localization via. methylene blue dilution injection, tailored gauze sizing, and bronchoscopic placement under direct visualization. Stability was ensured through forceps-guided positioning or supplemental metal stents in anatomically challenging cases. Post-procedure monitoring included chest X-ray, CT imaging, and clinical assessments at 1 day, 1 week, and 1 month. In a retrospective study of 19 patients with peripheral BPFs ≤ 5 mm who met predefined inclusion criteria (e.g., failed prior conservative therapy, high surgical risk) and exclusion criteria (e.g., untreated empyema, fistulas involving central airways), petrolatum gauze occlusion achieved 94.7% efficacy (18/19) at one week, with a low infection rate (15.8%). The observed efficacy, while promising, should be interpreted within the context of the study's limitations, including its small sample size (n = 19), single-center retrospective design, and potential for selection bias. Consequently, the generalizability of these findings to broader patient populations or other institutional settings may be limited. This cost-effective, adaptable technique demonstrates high success in sealing small-to-medium fistulas (≤5 mm), offering a safe alternative for high-risk populations, particularly in resource-limited settings. This article describes in detail the indications for this method, preoperative evaluation, intraoperative manipulation, and postoperative testing.

Introduction

Bronchopleural fistula (BPF) represents an aberrant communication between the pleural space and the bronchial system. Surgical interventions, particularly lobectomy and pneumonectomy, constitute the predominant etiological factors, with reported incidence rates of 0.4% and 1.9% respectively¹ and case-fatality rates ranging from 18% to 50%². Additional pathogenic contributors include infection, secondary to chemotherapy or radiotherapy-related impairments in lung cancer, refractory spontaneous pneumothorax, and, less frequently, mycobacterial tuberculosis infection³. Early detection and effective management of ....

Protocol

This study complied with the amended Declaration of Helsinki and was approved by the local independent ethics committees (Approval Number: EC.D(BG)025.04.0). All patients provided written informed consent for the off-label application of occlusive materials. The reagents and the equipment used are listed in the Table of Materials.

1. Inclusion criteria

1. Diagnose patients with BPF based on medical history, clinical presentation, radiological features, and endobronchial examination¹⁶, as mentioned below:
   1. Fistulas ≤5 mm in diameter located at or distal ....

Results

Retrospectively, 19 patients (10 males, 9 females; mean age 46.9 years ± 19.46 years) diagnosed with bronchopleural fistulae (BPFs) who were not suitable for surgical repair and underwent endobronchial closure with petrolatum gauze occlusion in the Endobronchial Intervention Center of Shanghai East Hospital from May 2018 to May 2024 were included (Table 2). The results showed that the overall effective rate on postoperative day 1 was 94.7% (18/19), of which 9 cases (47.4%) were completely cured, 9 cases .......

Discussion

The success of petrolatum gauze occlusion for the treatment of peripheral BPFs relies on meticulous execution of key steps. Firstly, the precise location of the fistula by retrograde injection of methylene blue dilution through the chest tube is essential to identify the culprit subsegmental bronchus. This technique is particularly valuable when the fistula orifice itself is not directly visible under bronchoscopy, as the dye efflux pinpoints the responsible airway segment. Second, gauze preparation (cut and folded into .......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Bronchoscopy equipment	Olympus Evis Lucera Elite	CV-290,CV-290SL
Carescape monitor	GE Healthcare Finland 0y	YZB/FIN 3498-2014
General anesthesia equipment	Dräger Medical GmbH	8606000-66
Laryngeal masks	TuoRen Medical	(21)000075 (91)001
Single-use  biopsy forceps	Changmei Medtech	FB-12C-B1
Underwater seal drainage (UWSD)	Tiantai County Kangsheng Medical	YY0583 sanqiang-1500
Ventilator	Mindray	SV350	2.8mm inner diameter