Management of a Patient with an Encapsulated Parapneumonic Empyema Complicated by the Intraoperative Development of an Acute Bronchopleural Fistula and ARDS

High frequency ventilation, another alternative strategy for management of BPF, has been advocated in patients with BPF as a conduit for providing adequate gas exchange at lower mean ventilation pressures 9. Various HFV approaches including high frequency jet ventilation (HFJV) and high frequency oscillatory ventilation (HFOV) have been proposed and utilized. HFJV employs high gas pressures provided through a small-bore cannula through the endotracheal tube. The small tidal volumes averaging 2 to 5 mL/kg provided at high frequencies ranging from 100 to 200 breaths per minute allows these benefits but also presents difficulties in gas warming and humidification. HFJV has been evaluated in case reports or case series of BPF. In general, HFJV may only be of benefit if the peak airway pressure is reduced with its use 10 (Figure 1). HFOV provides small gas volumes under constant mean airway pressures. Benefits of HFOV include active expiration, decreasing air trapping risks. HFOV, however, requires relatively high mean airway pressures (through auto-PEEP) and its successes have mainly been described in neonates. The successful use of a combination of ILV and HFOV has also been described 11. Intermittent inspiratory chest tube occlusion is another means by which a BPF can be managed. During inspiration, the chest tube is pressured from the ventilator thereby creating a brief pneumothorax and allowing other areas of the lung to be inflated 12 (Figure 2). The success of this technique has been described in case reports or small case series. However, special equipment is needed to be able to pressure the chest tube(s). Consequently, this method has not achieved widespread popularity.