Author information Article notes Copyright and License information Disclaimer. Masashi Iwasaki, Email: pj. Corresponding author. Received Dec 21; Accepted Feb The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.
Abstract Background Bronchopleural fistula, which usually accompanies bronchial fistula and empyema, is a severe complication of lung cancer surgery. Case presentation A year-old man, who was malnourished because of peritoneal dialysis, was referred to our hospital for the treatment of lung cancer.
Conclusions This bronchopleural fistula was treated successfully after a right lower lobectomy using an extra-pleural bronchial occlusion and negative-pressure wound therapy. Keywords: Negative-pressure wound therapy, Bronchopleural fistula, Open window thoracostomy, Bronchial occlusion. Background According to the National Clinical Database, bronchopleural fistula BPF is a severe complication of lung cancer surgery, occurring at a frequency of 0.
Case presentation A year-old male with a month history of peritoneal dialysis for chronic renal failure came to our hospital because of a 3. Open in a separate window. Discussion The BPF can be closed with several surgical and endoscopic procedures, including suturing of the fistula and intrathoracic transposition of the omentum [ 5 ] or muscle flaps [ 6 ], and application of a septal occluder device and fibrin glue by bronchoscopy [ 7 ].
Authors' contributions All authors attest that they meet the criteria for authorship. Funding No funding or grant support. Availability of data and materials Not applicable. Declarations Ethics approval and consent to participate Not applicable. Consent for publication The patient and his wife provided permission to publish this case report and any accompanying images. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References 1. Risk assessments for broncho-pleural fistula and respiratory failure after lung cancer surgery by National Clinical Database Japan. Gen Thorac Cardiovasc Surg. A Predictive score for bronchopleural fistula established using the French Database Epithor. Ann Thorac Surg. Intrathoracic vacuum-assisted management of persistent and infected pleural spaces.
Open window thoracostomy treatment of empyema is accelerated by vacuum-assisted closure. Omental flap for bronchopleural fistula post pneumonectomy and aorta replacement. Vacuum-assisted closure device: a useful tool in the management of severe intrathoracic infections. Amplatzer device and vacuum-assisted closure therapy to treat a thoracic empyema with bronchopleural fistula.
Throughout treatment, monitor the patient for any signs of local or systemic infection. If there are any signs of systemic infection or advancing infection at the wounded area, contact the treating clinician immediately.
If the RENASYS device reports a blockage alarm, inspect the dressing and canister tubing for any blockages which may be manually remedied. If a blockage cannot be identified or resolved, replace the device canister first, and then replace the dressing and Soft Port as necessary. Cover intact skin with transparent film wherever bridge will be placed. Layer additional foam or gauze on top of the wound filler and any film intended to support bridging materials.
Ensure contact with the filler in the wound cavity is made. Precautions should be taken for patients who are, or may be: Receiving anticoagulant therapy or platelet aggregation inhibitors. Suffering from wounds in close proximity to blood ves- sels or friable fascia. Sharp edges such as bone fragments must be covered or removed prior to initiating therapy, due to risk of punc- turing organs or blood vessels drawn closer under the action of negative pressure.
Remove the wound dressing only if its location will inter- fere with defibrillation. Ensure the abdo- men and its contents are adequately visualized, controlled and protected throughout application of the dressing.
CT scans and x-ray have the pctentia tc intertere with some electronic medical devices. Where possible, move the device cut ct the x-ray cr scanner range. Minima y, a weekly canister change is recommended. Always use the smallest practical canister size, based on the patients size and weight, to avoid risk of significant and or unintended fluid and blood loss.
Preventing adhesions or obstruc- tions that may otherwise form during open abdominal wound management is a critical parameter in achieving timely primary facial closure and reducing the chance of fistula development. The volume and appearance of the fluid in both canister and tubing should be checked and recorded frequently while patient is receiving therapy. The canister should be replaced prior to reaching tu -capacity.
The t uid eve in the canister may be used as an ap- proximate guide when considering the necessity of fluid resuscitation. Ensure any areas of necrosis are appropriately de- brided.
Clean and dry the periwound area. The OPL may be cut or folded to accommodate the specific needs of the patient. Remove kit contents from pouch and prepare the OPL cn a steri e tie d. Cent y pcsiticn the O dress- ing evenly into the abdominal cavity, distributing the sides into both of the lateral paracolic gut- ters.
Ensure complete coverage of all exposed bowel in the abdominal cavity with the OPL, prior to filling the wound defect with foam. Size the provided foam to the desired prcpcrticns a cng pre- scored perforations. Cutting the wound filler may be performed if desired. Do not cut the foam wound filler directly over the wound bed to avoid foam frag- ments from falling into the wound. Rub the edges of any cut foam, away from wound, to remove any loose fragments which may result. The foam should be placed directly over the OPL while maintaining contact with the margins of the wound.
Do not allow foam to contact intact skin without use of appropriate barrier, such as transparent film or a hydrocol- cid. Cent y p ace pertcrated tcam in the wound cavity over the OPL. Ensure that foam is sized to fit loosely into the wound defect and there is sufficient material to top the surface of the abdominal wound do not under fill the wound.
While holding the transparent film, expose one side of the adhe- sive backing by removing a single panel and apply it to the foam. Cover foam with transparent film, removing remaining adhesive panels to seal, as well as the re- maining carrier pane. NOTE: Overlap the edges of the transparent film by a minimum of 7. NOTE: Avoid stretching or pulling the transparent film to minimize tension or trauma to the periwound skin. Cut a small opening no less than 0. Ensure canister is installed correctly.
Connect the suction port tubing to the canister tubing by pushing the connectors together. An audible click indicates the con- nection is secure. The recom- mended pressure range is I20mmg. NOTE: When negative pressure is switched off, ensure the abdomen is adequately supported.
Remove and dispose of dressing per institutional protocol. Thoroughly inspect the wound to ensure all foam pieces have been removed. Count and record number of foam pieces removed. As with all adhesive products, apply and remove the dressing carefully from sensitive or fragile skin to avoid skin stripping especially if frequent dressing changes will be needed. Dressings should be changed every 48 hours, or more frequently, based on continual monitoring of patient ccnditicn.
Check dressings regularly and monitor the wound to check for signs of infection, bleed- ing cr abdcmina ccntaminaticn. Transparent Film 6 ea. Soft Port 1 ea. If sudden or increased bleeding is observed, immediately discontinue therapy, take apprcpriate measures tc stcp b eeding and ccntact the treating clinician. Patients suffering from difficult hemostasis or who are receiving anticcagu ant therapy have an increased risk ct b eeding. Sharp edges or bone fragments in a wound must be covered or remcved pricr tc using NwT due tc risk ct puncturing crgans cr blood vessels while under negative pressure.
In the event defibrillation is required, disconnect the NPWT device from the wound dressing prior to defibrillation. Remove the wound dressing if it will interfere with defibrillation. When operating, transporting, repairing or disposing of NPWT de- vices and accesscries, the risk ct intecticus iquids being aspirated, or contamination of the device assembly through incorrect use, can- nct be e iminated. NwT has nct been studied cn pediatric patients. NPWT is unsuitable for use in areas where there is danger of exp csicn le.
Receiving anticcagu ant therapy cr p ate et aggregaticn inhibitcrs, active y b eeding cr have weakened b ccd vesse s cr crgans. Suttering trcm ditticu t wcund hemcstasis. Ncnccmp iant cr ccmbative. Suttering trcm wcunds in c cse prcximity tc b ccd vesse s cr delicate fascia. The use ct NwT presents a risk ct tissue in-grcwth. Tissue in-grcwth may be reduced by reducing therapy pressure, using a wound contact layer or by increasing the frequency of dressing changes.
Regu ar mcnitcring ct the wcund shcu d be maintained tc check tcr signs of infection. There may be situations when the patient needs tc be disccnnected trcm the NwT device, tcr examp e for activities of daily living and diagnostic testing. If the patient needs to be disconnected, the dressing tubing should be clamped and the ends of the tubing protected. How long patients may be disconnected from the NPWT device is a clinical decision based cn individua characteristics ct the patient and the wcund.
As a condition of use, the NPWT device should only be used by qua itied and authcrized perscnne. The user must have the neces- sary kncw edge ct the specitic medica app icaticn tcr which NwT is being used. Ensure that tubing is insta ed ccmp ete y and withcut any kinks tc avcid eaks cr b cckages in the vacuum circuit. Position the NPWT device and tubing appropriately to avoid the risks ct causing a trip hazard and ct the patient ying cn the tubing.
At minimum, the canister shcu d be changed week y. Always use the smallest canister volume possible do not use the m canister cn patients with a high risk ct b eeding. Maintain regu ar mcnitcring ct the NwT device and wcund site during therapy to ensure therapeutic treatment and patient comfort. If any liquids penetrate the NPWT device, discontinue use and return tc ycur authcrized prcvider tcr service.
As with all adhesive products apply and remove the dressing caretu y trcm sensitive cr tragi e skin tc avcid skin stripping, espe- cially after frequent dressing changes. Canister kits are prcvided ncn-steri e and shcu d nct be used in a sterile field. Step 1: C eanse wcund area and pat dry per protocol.
Step 3: Ccver wcund bed, inc uding tistu a cpening, with ncn-adherent gauze cr with cne ayer ct sa ine mcistened gauze. Dressing Application Use aseptic or sterile techniques for application depending on insti- tutional protocol. If the objective is to bathe the wound surface for a period of time, the NPWT device should be turned off during that period. When the irrigation port is not in use, the cap should be applied to the port.
Caution: uti ize stcma paste underneath drain at wcund edge tc minimize pressure point. Step 5: i remaining wcund deticit with ad- diticna sa ine mcistened gauze. Precautions for Treating Enterocutaneous Fistulae Never ay drain direct y in ccntact with the intestina muccsa at the top of fistula opening. Recommendations Based on Fistula Location and Fluid Description The anatomical location of the fistula in the intestine will influence the amount and type of the output: The higher the tistu a cccurs in the bcwe , the thinner, mcre caustic and heavier the output.
The cwer the tistu a cccurs in the bcwe , the thicker cr pastier the output. Mcdity the app icaticn ct the igh Output 0ressing Kit as described below in accordance with the location and the fluid properties. Step 5: i wcund deticit with additicna sa ine mcistened gauze and ccntinue tc eave tistu a cpening expcsed. Step 1: Remove and dispose of dressing per institutional protocol. Thcrcugh y inspect the wcund tc ensure a gauze pieces have been removed. Step 6: Place transparent dressing over the wound and seal.
Step 7: Secure the 28 r drain with waterprcct tape. Step 8: Remove the canister tube supplied with the canister and discard. Step 9: Ccnnect the drain direct y tc the canis- ter by joining the blue connector of the drain to the canister input. Check that the dressing has a gccd sea. Step 2: As with all adhesive products, apply and remove the dress- ing caretu y trcm sensitive cr tragi e skin tc avcid skin stripping, especially if frequent dressing changes will be needed. Step 3: 0ressings shcu d be changed every 48 hcurs, cr mcre frequently, based on continual monitoring of patient condition.
In the event of heavy drainage, drainage with sediment or infected wounds, more frequent dressing changes may be needed. Step 4: Check dressings regu ar y and mcnitcr the wcund tc check for signs of infection or bleeding. If there are any signs of systemic infection or advancing infection at the wound site, contact the treating clinician immediately. Ccnsider bridging the twc wcunds using wcund ti er tcr wcunds separated by a distance arger than 25cm. Change Y-ccnnectcrs week y at a minimum, cr with each canister change.
Ccnnecting twc wcunds ct dittering intecticn status via the Y-ccnnectcr cr a bridge lncn-intected with intectedl is not recommended due to the risk of cross contamination. C cse y mcnitcr the dressinglsl when treating with a Y-ccnnectcr. Always check dressings for compressed appearance. If dress- ings are not visibly compressed, and no leak alarm has sounded, a blockage is present. If this occurs, replace one drain with a Soft Port. Therapy eve s ct 80 tc I20mmg are reccmmended when mu tip e wcunds are ccnnected with the Y-ccnnectcr.
C eanse the wcund bed and pat dry. Trim a sing e ayer ct ncn-adherent gauze and ay acrcss wcund bed. Cut the drain apprcximate y 2.
Cur the drain it using a channel or round drain. Warning: 0rain channe s must be ccntained within the wcund bed to achieve a seal. Apply a strip of ostomy paste to the wound edge to secure the drain in position; place the remainder over the top of the drain and pinch in place. Ccntinue tc app y gauze in ayers, unti the gauze ccse y ti s the entire wcund cavity. CAUTION: If using a drain with foam, ensure the drain is placed on top of the foam dressing and not in direct contact with the wound bed.
Ccver the wcund ti er with transparent ti m, removing the remaining adhesive panels to seal, then the tcp stabi izaticn pane. Create a sea by pinching the strip paste. Secure the drain tubing with waterproof tape. Notes: Avoid stretching or pulling the transparent film tc minimize tensicn cr trauma tc the periwcund skin.
Transparent i m shcu d extend at east 5cm beycnd the wcund margin and be securely anchored to the periwound area to main- tain a good seal. Cut a sma cpening lnc ess than 0. Remove the adhesive backing from the Soft Port dressing, and align the port opening directly over the hole in the transparent ti m. The recommended therapeutic pressure range is 80 tc I20mmg whi e a Y-ccnnectcr is uti ized during treatment. Notes: The vacuum level is a decision each healthcare provider must make, based on an individual assessment of the particular wound.
Adhere to the following general guidelines: cwer eve s ct vacuum are genera y ettective and mcre tc erab e. Do not use if package is open or damaged. PICO is intended for use in wound sizes surface area x depth up to Warnings 1. During therapy, avoid using hemostatic products that may increase the risk of bleeding, if disrupted.
MR Unsafe. Where PICO is used on patients with fragile skin, a skin protectant such as of skin where fixation strips are to be applied. If reddening or sensitisation occurs discontinue use and contact the treating healthcare professional. Ensure the end of the tubing attached to the dressing is facing Negative Pressure Wound Therapy Clinical Guidelines 73 5. Dressing change 1. If the dressing appears ready for changing button and disconnect the dressing from the pump. Apply another dressing as per section 7.
A Dressing properly positioned and is acceptable to be left in place B Dressing requires change Port may block with fluid C Dressing requires change Absorbent area is full A B C down so that water does not enter the top of the tube.
The port should be positioned uppermost on intact skin and not extend over the wound so that the risk of fluid collecting around the port and potentially blocking the negative pressure is minimised. Where possible, scanner range.
If the device has been check that it is functioning correctly following the procedure. Adverse Reactions Excessive bleeding is a serious risk associated with the application of suction to wounds which may result in death or serious injury. Instructions for use 7. Based on dressing change frequency, a new PICO Single Use Negative Pressure Wound Therapy System kit will be required dependent on either when both dressings have been used or after 7 days when the pump automatically stops functioning all the lights will turn off at this point.
The dressing should be disposed of as clinical waste. The batteries should be removed from the pump; and both batteries and pump disposed of according to local regulations. For additional information on disposal requirements see: www. Use with fillers and wound contact layers PICO is compatible with standard gauze and foam fillers used in traditional NPWT where this is clinically appropriate for example on a defect wound.
On infected wounds or wounds at risk of antimicrobial dressings may be used under PICO. General use 8. Showering and bathing Light showering is permissible; however, the pump should be disconnected see Precautions and placed in a safe location where it will not get wet. Faults and technical assistance If your device develops a fault or there are signs of damage, refer to Table 1. Application 1. The port should be uppermost from the wound depending on the patients primary position , placed on intact skin and not extending over the wound to prevent fluid pooling around the port and blocking the negative pressure.
Following this all three lights should flash once. Refer to Table 1. The green light will start to flash indicates system working OK, see Table 1. To troubleshoot refer to section ii of Table 1. The pump is OFF. The pump has reached the end of its life. The batteries are no longer functional. The therapy has been paused. Pressing the orange button will restart the therapy and the green light will flash. After 7 days of therapy the pump will automatically cease functioning, in this case all the lights will turn off.
Pressing the orange button will not provide a green flashing light. If the pump has had less than 7 days usage, the batteries may not be functional and should be replaced as below. All lights flash once. This reflects the pump self test once batteries have been inserted and the cover has been replaced.
This is expected. Table 1 Pump status indication, alarms and faults PICO has visual alarms to let the user know when there is an issue. Section i Normal function Green OK light flashes. Dressing applied, and full system is functioning properly. No issues. The pump may be heard running occasionally as it maintains the negative pressure. This is normal. If this occurs frequently several times an hour smooth down the dressing to remove any creases that may be allowing air into the system. NPWT is still being applied in this situation.
Safety and electromagnetic compatibility When used in accordance with the manufacturers instructions, PICO complies with the general requirements for safety of electrical medical equipment IEC requirements of electrical medical Electromagnetic compatibility This equipment has been tested and found to comply with the limits for medical designed to provide reasonable protection against electromagnetic interference typical of medical installations and home use environment.
This equipment generates, uses and can radiate radio frequency energy and if not installed and used in accordance with the instructions, may cause harmful interference to other devices in the vicinity.
However, there is no guarantee that interference will not occur in a particular installation. Guidance and manufacturers declaration electromagnetic immunity PICO is intended for use in the electromagnetic environment specified below. The healthcare professional or the user of PICO should assure that it is used in such an environment. Pump is in auto pause. NPWT is not being applied to the wound.
The pump will auto pause for 1 hour and then will automatically try to therapy if no remedial action is taken. Smooth down the dressing and the strips to remove any creases that are allowing air into the system. Press the orange button to restart the therapy. The green OK light will flash as the pump tries to establish therapy.
If the air leak remains, the amber leak light will start to flash after approximately 30 seconds. If this happens, repeat smoothing actions and press the orange button. If the leak is resolved the green light will continue to flash. Section ii Alarms and faults Green OK light flashes. Amber battery low light flashes.
Amber leak light flashes. All lights solidly illuminated. System on and functioning properly. Battery power low. Pause the therapy by pressing the orange button. Push open the battery cover at the top of the pump and remove the old batteries. Insert 2 new lithium L91 batteries. Press the orange green light will flash.
Address air leak as above. Pump failed. System is not usable. Apply new pump and dressing. The healthcare professional or the user of PICO can help prevent electromagnetic interference by maintaining a minimum distance between portable and mobile RF communications equipment transmitters and PICO as recommended below, according to the maximum output power of the communications equipment.
Note 1: At MHz, the separation distance for the higher frequency range applies. Note 2: These guidelines may not apply in all situations.
Electromagnetic propagation is affected by absorption and reflection from structures, objects and people. Guidance and manufacturers declaration electromagnetic emissions PICO is intended for use in the electromagnetic environment specified below. To assess the electromagnetic environment due to fixed RF transmitters, an electromagnetic site survey should be considered. If abnormal performance is observed, additional measures may be necessary, such as reorienting or relocating PICO.
Therefore, its RF emissions are very low and are not likely to cause interference in nearby electronic equipment. It is intended only as a guide. For medical questions please consult a physician. The product must be used in accordance with this user guide and all applicable labelling.
Alternatively, a bag for carrying the pump is also available. Immunity test Electrostatic discharge ESD Electromagnetic environment guidelines Floors should be wood, concrete or ceramic tile.
Field strengths from fixed RF transmitters, as determined by an electromagnetic site survey a , should be less than the compliance level in each frequency range.
Glossary of symbols Negative Pressure Wound Therapy Clinical Guidelines 77 Appendix VII Frequently asked questions and answers What is the suction pressure of your machine or the range of pressure that the machine achieves? The pressure is pre-set on the PICO system and it operates at continuous negative pressure of nominally 80mmHg.
Can it be changed? With both pumps, the pressure can be set at different levels. The device resumes at the same level of pressure as was set when it was last turned off or put on standby.
The pressure cannot be changed on the PICO system. Is there an Intermittent feature? Is there a cut off which stops suction if the canister is full? An audible alarm will sound and a visual light flashes when the canister is full, but the devices do not turn off. The PICO system is canister-free. The larger the PICO dressing, the more fluid can be managed. Traditional NPWT may be the best option to manage wound fluid that is expected to exceed greater than 50cc in 24 hours.
Is there a one-way valve to prevent fluid from coming back through the tubing towards the patient? How long does the battery last? Cut the foam dressing to fit the size and shape of the wound and place into wound cavity.
Center the film portion of the dressing over the insertion point of the drain tubing. Tip: Centering the film over the tube insertion site facilitates a film to film seal around the hole establishing a good seal. Position drain on top of gauze. Secure the drain tubing with waterproof tape utilizing the Chevron Technique. Ensure canister is installed correctly, connect the drain to the canister and begin vacuum. Place transparent dressing over the wound and seal.
Create a seal by pinching the ostomy paste. If no leak is present and the patient is comfortable, dressing changes should occur times per week. Foam wound dressings should be changed every 48 hours during therapy. Capping off tubing Connecting the tubing Caution: Do not connect tubing to or cover the open end of the T-connector that is inserted in the canister tubing.
Installing the canister - Remove paper tape around the canister tubing to release tubing to the full length. Start up of device Press and hold the Power button for 2 seconds until start up message appears.
Select vacuum setting 4. Start therapy Use Up and Down to adjust. A prospective randomized evaluation of negative-pressure wound dressings for diabetic foot wounds. Ann Vasc Surg. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: a multicenter randomized controlled trial.
Diabetes Care. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure V. J Vasc Surg. The clinical effectiveness of negative pressure wound therapy: a systematic review. J Wound Care ; Erratum for: J Wound Care. A novel option in negative pressure wound therapy NPWT for chronic and acute wound care.
Wagner FW. A prospective randomised evaluation of negative-pressure wound dressings for diabetic foot wounds. Vacuum- assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot.
Ostomy Wound Manage. Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int. Ann Acad Med Singapore. Evidence-based recommendations for negative pressure wound therapy: treatment variables pressure levels, wound filler and contact layer — steps towards an international consensus. J Plast Reconstr Aesthet Surg. Full text links Read article at publisher's site DOI : Smart citations by scite.
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Novel negative pressure wound therapy device without foam or gauze is effective at mmHg. Similar Articles To arrive at the top five similar articles we use a word-weighted algorithm to compare words from the Title and Abstract of each citation. Effectiveness of vacuum-assisted closure VAC therapy in the healing of chronic diabetic foot ulcers. Poorly designed research does not help clarify the role of hyperbaric oxygen in the treatment of chronic diabetic foot ulcers. Systematic reviews of wound care management: 3 antimicrobial agents for chronic wounds; 4 diabetic foot ulceration.
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