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Bronchopleural fistula after a pneumonectomy: the sign that cannot wait | CION Cancer Clinics
A bronchopleural fistula is a small opening at the closed end of the airway where the lung was removed. Air leaks into the empty chest space, and the fluid collected there can spill back into the airway. It is uncommon, but it needs same-day care. This page explains the warning signs, how to lie while you get to hospital, and what the team will do once it is confirmed. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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On this page
- What is a bronchopleural fistula after a pneumonectomy?
- The signs, from the most obvious to the easiest to miss
- What the team does once a fistula is suspected
- Words you will hear, in plain language
- What this page cannot tell you
- Four things families tell us, and what is actually true
- Common questions about a fistula after lung removal
The short answer
What is a bronchopleural fistula after a pneumonectomy?
A bronchopleural fistula is a small opening at the sealed end of the airway where the lung was cut away. Air leaks into the empty chest space, and the fluid collected there can leak back into the airway. It is uncommon, but it is the complication surgeons worry about most, and it needs treatment the same day it is suspected.
Why the stump can open
When a whole lung is removed, the main airway to it is closed with staples or stitches. That closed end is the stump. It has to heal in a space with no lung tissue around it to support it. If healing is slow, or the stump is under strain, a gap can appear along the staple line. It is more likely after removal of the right lung, after radiotherapy or chemotherapy before surgery, with diabetes, and in people who are weak or poorly nourished going into the operation.
When it happens
Most open in the first days or weeks after surgery. A few open months later, because of infection in the space or because the cancer has come back near the stump. A late opening is easy to mistake for a chest infection, which is why the warning signs matter long after discharge.
This page cannot tell you how likely it is for you; that depends on your operation and your health.
!
Go the same day, and lie the right way while you go
Suddenly coughing up thin, watery, frothy or foul-smelling fluid, especially when lying down, is the sign that cannot wait. Go straight to an emergency department and say a lung has been removed and the stump may have opened. On the way, sit up or lie with the operated side down, so the fluid stays away from the remaining lung. Do not lie flat and do not lie on the good side.
Not sure whether this applies to you?
Ask an oncologistWhat it looks like
The signs, from the most obvious to the easiest to miss
Coughing up fluid
The clearest sign. The fluid in the chest space finds its way through the gap into the airway, and you cough it up. It is thin and may taste unpleasant, and it gets worse when you lie down or turn towards the good side.
Fever and feeling unwell
Once air and germs reach the space, the fluid there can become infected. The person feels generally ill, sweaty, off their food, with a temperature that keeps returning.
Often mistaken for
- An ordinary chest infection
- A wound infection
New breathlessness
Fluid reaching the remaining lung makes breathing harder, sometimes quickly. Any sudden worsening of breathing after a pneumonectomy is treated as this until proved otherwise.
A change on the X-ray
The fluid level in the empty space should rise steadily. If it drops between two films, air has got in from somewhere. Your surgeon may spot this before you feel anything, which is one reason the early X-rays are done.
Air under the skin of the chest or neck, felt as a crackling, is another clue the team looks for.In hospital
What the team does once a fistula is suspected
Protect the remaining lung
You are sat up or turned onto the operated side straight away. Oxygen is given. If the leak is large, a tube is placed into the space to let fluid out so it cannot spill into the airway.
Look at the stump
A thin camera is passed down the airway to see the closed end directly. This confirms whether there is a gap, how big it is and whether the tissue around it looks healthy. A CT scan usually goes with it.
Treat the infection
Antibiotics are started through a drip, chosen once the fluid has been sent for testing. The space is drained and often washed out. This stage can take days to weeks, and nutrition is built up at the same time because healing depends on it.
Close the gap
A very small gap may seal on its own or be plugged through the camera. A larger one needs an operation, where the stump is re-closed and covered with a flap of living muscle that brings its own blood supply. Which method depends on the size of the gap and how well you are.
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On your report
Words you will hear, in plain language
- Bronchial stump
- The closed end of the main airway where the lung was removed. The fistula is a gap in it.
- Empyema
- Infected fluid, or pus, in the chest space. It almost always goes with a fistula and is treated alongside it.
- Bronchoscopy
- The camera test that looks at the stump from inside the airway. Done under sedation or a short anaesthetic.
- Open window
- A small opening made in the chest wall so the infected space can be cleaned and packed daily. It is closed later once the space is clean.
- Muscle flap
- A piece of nearby muscle, still attached to its blood supply, brought inside the chest to cover the re-closed stump and help it heal.
- Thoracoplasty
- An operation that lets the chest wall sink in to close down the space. Now rarely needed.
Being straight with you
What this page cannot tell you
It cannot tell you whether your cough is a fistula. A cough after a pneumonectomy is common and usually harmless. What separates the two is the fluid that comes up, the timing, and what the X-ray and camera show. Only a team that can examine you can say.
It cannot give you a number for your own risk
The chance varies a great deal between people. It is higher after a right-sided operation, after treatment before surgery, with diabetes, and where the stump was not covered with tissue at the first operation. Ask your surgeon whether the stump was covered, and what they consider your own risk to be. That is a fair question.
It cannot say how long treatment will take
A small early leak may settle within days. An infected space with a large gap can mean weeks in hospital, more than one procedure and a period of daily dressings at home or in a district hospital. Families should plan for the longer road and be pleased if it is shorter.
Ask who to call at night. A fistula does not wait for clinic hours, and knowing the number before you need it saves time when it matters.Commonly believed
Four things families tell us, and what is actually true
"It is just a chest infection. We will finish the
tablets first."
A fever with fluid coming up after a pneumonectomy is not treated as an ordinary infection. Waiting to finish a course of tablets lets fluid keep spilling into the only lung you have. Call, or go, the same day.
"The surgeon must have made a mistake."
A stump can open even after careful surgery, because it has to heal in an empty space with a poor blood supply. Surgeons take steps to lower the chance, but no technique removes it. Asking what was done is reasonable.
"Once it is closed, it cannot open again."
It can, particularly if infection in the space was not fully cleared or if the cancer returns near the stump. This is why the follow-up after a repair is close, and why the warning signs stay relevant for a long time.
"Lying on the operated side will squash the
remaining lung."
The opposite. Lying with the operated side down keeps any fluid in the empty space away from the good lung. It is the safest position while you wait for help.
Questions we are asked
Common questions about a fistula after lung removal
How would I know the difference between this and a normal cough?
A normal cough after surgery brings up little or nothing, or thick phlegm. A fistula brings up thin, watery or frothy fluid, often a lot of it, and it is worse when you lie down. If you are unsure, treat it as the serious one and call.
Can it happen months after the operation?
Yes. Most open early, but a late opening does happen, because of infection in the space or because the cancer has come back near the stump. A new fever or new fluid coming up at any time after a pneumonectomy should be seen the same day.
Why is the right side more at risk?
The right main airway is shorter and wider, and it has less surrounding tissue to cover the stump once the lung is gone. That leaves the closed end more exposed and with a poorer blood supply. Surgeons often bring a flap of tissue over a right-sided stump for this reason.
Will I need another operation?
Not always. A very small gap can seal with drainage, antibiotics and time, or be plugged through the camera. A larger gap, or one with an infected space, usually needs the stump re-closed and covered with a muscle flap. Your surgeon will say which applies once they have seen the stump.
What is the open window, and will it be permanent?
It is a small opening in the chest wall that lets the infected space be cleaned and packed each day. It is not permanent. Once the space is clean and the stump has healed, it is closed in a further operation. Nurses will teach the family the dressing.
Can I eat and drink normally during treatment?
Eating well is one of the most useful things you can do, because the stump heals only if the body has the protein to heal it. If appetite is poor, the team may add supplements or feed through a tube for a time. Say early if food is a struggle.
Is it covered by Aarogyasri or insurance?
Treatment of a complication of cancer surgery is usually covered under the same approval, but the extra stay and any further operation may need a fresh authorisation. Aarogyasri, CGHS, ECHS and EHS are accepted, and most cashless insurers are empanelled. Call the helpline with your card details and we will check.
Could this have been prevented?
Surgeons lower the chance by keeping the stump short, covering it with tissue, controlling blood sugar and building up nutrition before surgery. None of that removes the risk entirely. If it has happened, the useful question now is what the plan is.
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Dr. C. Raghavendra Reddy
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Dr. Muralidhar Muddusetty
MBBS (AIIMS), MS (Surgery) (AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh)
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Dr. Vinay Mamidala
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Sources
- Cancer Research UK — Surgery for lung cancer
- NHS — Lung cancer: treatment
- American Cancer Society — Surgery for non-small cell lung cancer
- National Cancer Institute — Lung cancer
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
What fills the space where the lung wasThe fluid that spills into the airway when the stump opensLeft vs right pneumonectomy: why it mattersWhy a right-sided stump is more at riskInfections and chest care with one lungTelling a chest infection from something more seriousComplications and red flagsEvery same-day warning sign after cancer surgeryCaretaker and family guide to surgeryWhat the family needs to know before discharge
Talk to us
Coughing up fluid after a lung was removed?
Go to the nearest emergency department now. If you are unsure whether what you are seeing is serious, call the helpline and a CION surgical oncologist will tell you what to do next. One helpline serves every CION centre.