The management of complex bronchopleural fistulas (BPFs) remains a major diagnostic and therapeutic challenge to all chest physicians. Successful management of a fistula revolves around treatment of the associated empyema cavity first. Definitive repair should be accomplished expeditiously to minimize the number of procedures performed. When treatment is protracted, secondary complications are more likely to develop and survival is adversely affected. Diagnosis and localization of a BPF is therefore paramount; however, it is sometimes difficult and may require multiple imaging studies and bronchoscopies. Herein, we describe our experience with computed tomography bronchography as a new technique for diagnosis and localization of difficult BPF. In addition, other modalities for diagnosis and medical management are discussed along with a relevant review of the literature.