eComment. Is the problem the duration of mechanical ventilation or how it is performed?

We read with interest the article of Toufektzian et al. [1] on the development of bronchopleural fistula after prolonged mechanical ventilation.

In our experience we also have found a higher incidence of bronchopleural fistula in pneumonectomies after prolonged mechanical ventilation (P = 0.001), but we had defined “prolonged ventilation” as one that was longer than 24 h and when attempts to remove the orotracheal tube had failed. We think that in the literature, there is a high variability of this definition. For example, Wright et al. performed early extubation at the end of surgery [2], but in our experience, we noted that is not always possible, because one has to consider the timing of the procedure and the patient's condition. Another point of interest is that the ventilation protocol is not the same for every patient. In fact, many variables could affect the ventilation: volume support, pressure support, positive end-expiratory pressure, respiratory rate etc. These are often chosen by the anaesthesiologist during the surgery, and this could vary from centre to centre. In fact, the incidence of bronchopleural fistula is not 100% in patients undergoing prolonged mechanical ventilation, but fistulas occur only in a small subset of patients. Thus, the duration of the ventilation is probably not the only risk factor during invasive ventilation [3,4], but is variable regardless of the length of ventilation [3,4]. Perhaps the right question should be: is the problem the duration of mechanical ventilation or how it is performed?

Finally, we also noted a higher incidence of fistulas in patients with preoperative lung infection, with no statistical significance at multivariate analysis, as other authors have observed [4,5]. In this case, we think that it is a correlate problem, because preoperative lung infection could create parenchymal damage and aggravate respiratory functionality, increasing the risk of prolonged mechanical ventilation. Based on the data reported, we would really appreciate the Authors' reflections and reaction.

Conflict of interest: none declared.

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