A preterm infant on pressure-control ventilation for 12 days develops a bronchopleural fistula. Which ventilation strategy is recommended?

• A. Exogenous surfactant therapy
• B. Volume control ventilation
• C. High frequency ventilation
• D. Nitric oxide therapy

Answer: (C)

Minimizing air leak and lung injury is key when a bronchopleural fistula develops. A fistula allows air to escape into the pleural space with conventional breaths, so you want to keep peak pressures and tidal volumes as low as possible while still delivering adequate gas exchange. High frequency ventilation achieves this by delivering very small tidal volumes at a very high rate, with careful control of the mean airway pressure. This approach reduces the peak inspiratory pressures that drive air through the fistula and lowers the risk of further pneumothorax, while maintaining oxygenation and allowing the fistula to heal. Exogenous surfactant can help with surfactant deficiency, but it doesn’t address the leak itself. Volume-controlled strategies tend to deliver larger tidal volumes that can worsen air leaks. Nitric oxide targets pulmonary hypertension and is not specifically addressing a bronchopleural fistula. So, switching to high frequency ventilation best fits the goal of minimizing air leak and protecting the lung in this scenario.