29. Pleural Disease Part 2: Hemothorax & BPF with Dr. Michal Sobieszczyk, MD

Hemothorax and persistent bronchopleural fistula require nuanced clinical management to minimize patient morbidity. Post-traumatic hemothorax is diagnosed when the pleural hematocrit exceeds 50% of the serum value, and initial treatment favors small-bore chest tubes to reduce risks of intercostal injury or parenchymal damage. Failure to drain residual hemothorax risks complications like empyema or fibrothorax, necessitating escalation to fibrinolytic therapy or surgical evacuation. Persistent bronchopleural fistula, defined as an air leak lasting over seven days, demands a conservative approach focused on lung rest through ventilator optimization and minimizing suction. When these measures fail, advanced interventions such as autologous blood patches, talc pleurodesis, or endobronchial valves provide effective alternatives. In extreme cases, VV ECMO offers the ultimate strategy for lung rest, allowing the fistula time to heal without the trauma of positive pressure ventilation.