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The Prevention and Management of Air Leaks Following Pulmonary Resection
T h e Pre v e n t i o n a n d M a n a g e m e n t o f A i r Le a k s F o l l o w i n g Pu l m o n a r y R e s e c t i o n Bryan M. Burt, MDa, Joseph B. Shrager, MDb,c,* KEYWORDS Pulmonary resection Postoperative Air leak Alveolar pleural fistula
KEY POINTS Based on preoperative risk factors, selected patients should be considered for intraoperative techniques to minimize air leaks and the residual spaces that predispose to prolonged air leaks, including pleural tenting and pneumoperitoneum. There is insufficient evidence for the routine use of surgical sealants following pulmonary resection; we recommend buttressing staple lines in nonanatomic pulmonary resections for patients with moderate to severe emphysema (forced expiratory volume in 1 second <60% of predicted) to prevent prolonged air leaks. In postoperative patients with less than a large air leak and no more than a small pneumothorax, algorithms incorporating no applied external suction or alternating suction likely reduce the duration of air leak. Initial evaluation of digital drainage systems suggest that their use may result in shorter duration of air leak, duration of chest tube, and length of stay. Most prolonged alveolar air leaks resolve with time and tube drainage alone, and a trial of a few weeks of watchful waiting incorporating a Heimlich valve is reasonable in the outpatient setting.
Alveolar air leaks after pulmonary resection are a common problem in thoracic surgery. A variety of reports have shown that an air leak is present immediately on completion of a routine pulmonary resection in 28% to 60% of patients, after both lobectomies and lesser resections. On the morning of postoperative day 1, an air leak is present in 26% to 48% of patients; on the morning of postoperative day 2, an air leak is present in 22% to 24% of patients; and on the morning of postoperative day 4, an air leak is present in 8% of patients.1
A contemporary, practical definition of prolonged air leak (PAL) is an air leak that persists beyond postoperative day 5. This definition is used by the Society of Thoracic Surgeons database and represents a leak whose duration exceeds the average length of stay (LOS) for lobectomy. Several studies have found that PAL is associated with an increased rate of postoperative complications following routine pulmonary resection. Brunelli and colleagues2 reported an 8.2% to 10.4% rate of empyema in patients who had an air leak lasting more than 7 days, compared with a 0% to 1.1% in patients with lesser air leaks. Similarly,
Disclosures: Dr J.B. Shrager is a consultant for Maquet, Inc. a Division of Thoracic Surgery, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030, USA; b Division of Thoracic Surgery, Stanford Hospitals and Clinics, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building CV-207, Stanford, CA 94305, USA; c Division of Thoracic Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA * Corresponding author. Division of Thoracic Surgery, Stanford Hospitals and Clinics, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building CV-207, Stanford, CA 94305. E-mail address: [email protected] Thorac Surg Clin 25 (2015) 411–419 http://dx.doi.org/10.1016/j.thorsurg.2015.07.002 1547-4127/15/$ – see front matter Published by Elsevier Inc.
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INTRODUCTION
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Burt & Shrager Varela and colleagues3 found that air leaks lasting at least 5 days postoperatively were associated with increased pulmonary morbidity, including atelectasis, pneumonia, or empyema. In the lung volume reduction surgery (LVRS) population, postoperative complications occur more often in patients experiencing air leak (57%) than in those who do not (30%).4 Several risk factors for PAL following pulmonary resection have been identified. The most consistently identified risk factor for PAL is chronic obstructive pulmonary disease (COPD). Preoperative tests reflecting the severity of COPD and that are associated with PAL include reduced postoperative predicted forced expiratory volume in 1 second (FEV1), FEV1 less than 79% of predicted, FEV1 less than 1.5 L, FEV1 less than 70%, and both FEV1 and forced vital capacity less than 70%.1 Other risk factors with proven associations with PAL include carbon monoxide diffusion in the lung less than 80%, presence of adhesions, upper lobectomy and bilobectomy, presence of a pneumothorax coinciding with an air leak, and steroid use.1
THERAPEUTIC OPTIONS AND CLINICAL OUTCOMES Intraoperative Prevention of Air Leaks Because PALs are common, clearly increase LOS, and likely cause associated complications, several surgical strategies have been developed to prevent them. The general principles underlying these surgical techniques involve an elimination of residual space and achieving apposition of the visceral pleura, either to the parietal pleura or to transposed tissue (Table 1). Other techniques include addressing pulmonary resection beds and staple lines with adhesives and/or buttressing material. Routine performance/use of these techniques is not advisable; not all patients are expected to benefit from these intraoperative adjuncts, which can be time consuming and/or costly. A careful selection of patients for such techniques should be based on underlying risk factors and probability of PAL and pleural space problems. For example, small or moderate residual spaces after pulmonary resection in many patients are physiologic and inconsequential; they resolve over time without ill effect. However, a large residual space in the context of a patient at high risk for air leak, which may result in infection of that space, can lead to a cascade of untoward events and morbidity. There are several intraoperative measures for preventing residual air spaces with which a thoracic surgeon should be familiar and many of
Table 1 Intraoperative procedures to manage residual thoracic air spaces
Anatomic Structure Parietal pleura
Visceral pleura Diaphragm Muscular chest wall
Osteotendinous chest wall Omentum
Intraoperative Procedure Pleural tent Pleurectomy or pleurodesis Adhesiolysis Decortication Pneumoperitoneum Phrenic nerve paralysis Intrathoracic transposition of muscle Rib resection at thoracotomy level Tailored thoracoplasty Omental transposition
these have randomized studies establishing their effectiveness. Lung mobilization Although less often a problem after sublobar resection compared with lobectomy, attaining pleural apposition without having to resort to high levels of suction seems to be an effective strategy for preventing PALs. There are several techniques that are commonly used to minimize residual space. Mobilization of all intrapleural adhesions and division of the inferior pulmonary ligament are the simplest of these, and should be routinely practiced because they are helpful. Similarly, decortication of the remaining lung, in rare instances and when required, may facilitate pleural apposition. Pleural tent Creation of an apical pleural tent at the time of upper lobectomy or upper bilobectomy (resection of upper and middle lobes) is a proven technique for decreasing PAL. A pleural tent is created by detachment of the parietal pleura from the endothoracic fascia, usually beginning at the level of the thoracotomy or one of the upper thoracoscopic port sites. The pleura is elevated circumferentially along the chest wall, being careful not to tear it. The resulting pleural tent falls directly onto the staple lines along the interlobar fissures. It compartmentalizes the chest cavity by separating the caudally located, fully drained space, which contains the residual lung, from the cranially located undrained space, which is allowed to fill
Air Leaks Following Pulmonary Resection with serum. Three randomized trials in patients undergoing lung resection have shown that pleural tenting performed at the time of lung resection decreases chest tube duration and mean hospital stay5; decreases incidence of postoperative air leak6; and decreases air leak duration, chest tube duration, length of hospital stay, and hospital costs.7
severe emphysema undergoing lobectomy. However, as far as we know, this is purely theoretic, because the sealants have never been studied in this population. However, the fact that 1 study shows substantially reduced air leaks in patients after LVRS on the side treated with a sealant versus the control side not treated with sealants is suggestive.15
Pneumoperitoneum Creation of pneumoperitoneum at the time of lower lobectomy or lower bilobectomy (resection of middle and lower lobes) has also been shown to decrease PAL, time of chest tube drainage, and LOS.8,9 This step can be accomplished with a catheter placed transdiaphragmatically (through a purse-string suture) during the chest procedure or through a catheter or Veress needle, placed transabdominally in a manner similar to placing a laparoscopic port. Transient diaphragmatic paralysis via injection of the phrenic nerve with a local anesthetic has been described and can serve a similar purpose.10
Staple-line buttressing The routine use of staple-line buttressing has also shown variable results. In severe emphysema (eg, LVRS), randomized data suggest that buttressing is effective for decreasing postoperative air leak and decreasing the duration of chest tube drainage and hospital stay.16,17 Less robust data are available for patients undergoing anatomic resection. For example, one prospective randomized trial was performed in which 80 patients, undergoing lobectomy or segmentectomy, were assigned to receive staple-line buttressing with pericardial strips or standard treatment. This trial showed no advantage of buttressing with regard to time to chest tube removal or hospital stay, and there was only a trend toward reduced duration of air leak.18 We recommend buttressing staple lines in nonanatomic pulmonary resections for patients with moderate to severe emphysema (FEV1<60% of predicted) to prevent PALs.1 In lobectomies (perhaps other than the horizontal fissure divided during right upper and middle lobectomies), the fissures are generally fairly thin and do not seem to require buttressing.
Surgical sealants A Cochrane Database Review has evaluated the use of surgical sealants for the prevention or reduction of postoperative air leaks following pulmonary resection. This review included 16 randomized trials and 1642 patients.11 Only 6 trials were able to show a significant reduction of postoperative air leaks by the use of sealants, and 3 trials showed a significant reduction in time to chest tube removal in the treatment group. These benefits (shown in a minority of trials) did not generally translate into reduced length of hospital stay, and we agree with the investigators of the Cochrane Review in not recommending routine use of these surgical sealants in patients undergoing pulmonary resection. A polymeric biodegradable hydrogel sealant (Progel) is the only sealant currently US Food and Drug Administration approved for intraoperative use during pulmonary resection. A randomized trial has suggested that intraoperative application of this product may reduce postoperative air leaks and result in 1less hospital day. However, Progel did not result in any difference in duration of chest tubes, so it is hard to attribute the reduced LOS to the product.12 We, and other investigators who have reviewed available data on lung sealants, have come to similar conclusions: that the current evidence does not support the routine use of these products in pulmonary resection.13,14 However, it is possible that sealants may eventually be shown to provide some measureable benefit in patients at high risk for PAL; for example, those with moderate to
Tissue transposition Intrathoracic transposition of muscle flaps can function to obliterate residual spaces and, similar to a pleural tent, can be used to partition the thoracic cavity (muscle tent). Muscle transposition should be considered at the time of initial operation in cases in which complex, infected residual spaces may be created following lung resection. Serratus anterior and latissimus dorsi flaps can be transferred together or separately into the chest. Preserving the thoracodorsal vascular pedicle, both of these muscles can be transposed through a window created in the chest wall by resection of a 5-cm segment of the second or third rib.19,20 In selected circumstances, the omentum can similarly be transposed into the thoracic cavity to fill the base of the chest,21 either through the anterior diaphragmatic muscle or through a substernal, mediastinal tunnel. Other techniques Other often-practiced, but less studied, techniques for intraoperative prevention of air leak include minimizing dissection within the fissures,
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Burt & Shrager minimizing inspiratory pressures when reinflating the lung, careful attention to avoid overlapping parenchymal staple lines, and closing the surgical stapler slowly in thick tissues. Another potentially useful approach is what has been termed the fissureless technique of lobectomy, which is often performed during videoassisted thoracoscopic surgery lobectomy. In a prospective study of lobectomy, 63 patients with incomplete or fused fissures were intraoperatively randomized to receive either the traditional technique or the fissureless technique to approach the fused fissures. The incidence of PAL was significantly higher among patients with incomplete or fused fissures, and a fissureless lobectomy technique that avoided dissection of the lung parenchyma over the pulmonary artery resulted in significantly decreased PAL and reduced hospital stay.22 Our opinion is that attention to these intraoperative details may be at least as effective as the commercially available sealants and other costly approaches.
Postoperative Management of Air Leaks During the initial management of a postoperative air leak, whether the leak originates from the alveoli through a peripheral tear in the visceral pleura (alveolar air leak) or from a bronchial structure (a bronchopleural fistula) can be hard to definitively determine. However, almost all postoperative air leaks are alveolar in origin, and the initial management therefore should be focused on treating this entity. Postoperative chest tube management Many thoracic surgeons prefer to manage postoperative chest tubes using external suction following lung resection in efforts to improve lung expansion, minimize residual pleural spaces, and to reduce the risk of system malfunction secondary to blood clotting. Other thoracic surgeons think that suction may prevent air leaks from sealing by increasing air flow through visceral pleural defects, and that air leaks are therefore more likely to seal with no applied external suction. A traditional practice is to place chest drains to 20 cm H2O suction after pulmonary resection and then to convert the tubes to water seal when there is no visible air leak. The early LVRS experience led many clinicians to question this traditional practice, with experience with these patients with severe emphysema suggesting that placing the chest tubes of patients having LVRS to the traditional 20 cm H2O of suction caused PALs and led to significant problems.23,24 Surgeons who have performed substantial numbers of LVRS procedures have no doubt that this is the case. This LVRS experience stimulated
surgeons to study whether a no–external-suction algorithm can reduce air leak and PAL after nonLVRS pulmonary resections as well. Six randomized trials have been published assessing the management of chest tubes with external suction compared with those with no external suction applied25–30 (Table 2). Three trials showed an advantage in duration of air leak, time to chest tube removal, and/or length of hospital stay for the early water seal modality.25,26,28 Two trials did not find a difference in these metrics.27,29 One trial found that external suction ( 15 cm H2O) reduced the duration of persistent air leak after anatomic lung resection compared with no external suction.30 Significant differences in study design of these 6 trials may have resulted, to some degree, in the variability of their results. These differences included differences in the degree of external suction in the suction arm ( 10, 15, 20 cm H2O), differences in the times at which the chest drains were placed to suction (in the operating room, on postoperative day 1, or by alternating suction and no suction algorithms), definitions of PAL, drainage systems (traditional versus leak meter systems, and portable systems that may better facilitate ambulation [discussed later]), study participants (all patients vs those with visible air leak only), resection type (anatomic resection and nonanatomic resections), as well as the use of chest radiographs to evaluate pneumothorax. For example, the only study that reported a benefit to external suction followed a different algorithm from the other studies: patients were randomized to no external suction or to 15 cm H2O on postoperative day 1, and subsequently all patients’ tubes were placed to Heimlich valve on postoperative day 3.30 We interpret the balance of evidence from these randomized trials to suggest that some version of reduced or part-time suction likely decreases the duration of air leak after pulmonary resection in most patients. However, the ideal algorithm remains uncertain. Although there is no high-level evidence available to date specifically in patients with severe emphysema, expert consensus and extensive clinical experience (in LVRS) suggest that patients with obstructive lung disease and an FEV1 less than 45% of predicted are optimally treated with no external suction applied in the absence of a large, symptomatic, or growing pneumothorax; progressive subcutaneous emphysema; or clinical deterioration. The traditional 20 cm H2O of suction is clearly counterproductive in these patients. For patients without severe emphysema, we think that available evidence suggest that either alternating suction (alternating 10 cm H2O of
Air Leaks Following Pulmonary Resection
Table 2 Randomized trials evaluating no external suction (NES) algorithms following pulmonary resection
Author
Algorithm
N
Resections
CXR Benefit of Evaluation NES
NES on POD 2 33 Lobectomy, Yes Cerfolio after 20 cm H2O sublobar et al,25 2001 NES after 20 cm 68 Lobectomy, Yes Marshall H2O while in OR sublobar et al,26 2002 145 Lobectomy No Brunelli et al,27 NES on POD 1 2004 after 20 cm H2O Brunelli et al,28 2005
Alphonso et al,29 2005
Leo et al,30 2013
Alternating 10 94 Lobectomy No cm H2O (day) and NES (night) vs full-time NES, after 10 cm H2O Immediate NES 239 Lobectomy, No sublobar
NES or 15 cm H2O on POD 1, all tubes to Heimlich valve on POD 3
500 Lobectomy, Yes sublobar
Yes Yes No
Yes
Comments Greater sealing of AL by POD 3 Reduced duration of AL Increased complications with NES Fewer PALs, shorter tube duration and LOS
Yes
No differences in PAL or tube duration but increased mobilization with NES Reduced PAL No (there duration with was a 15 cm H2O benefit suction in the to 15 cm anatomic H2O) resection subgroup
Abbreviations: AL, air leak; CXR, chest radiograph; OR, operating room; PAL, prolonged air leak; POD, postoperative day. Data from Refs.25–30
suction at night with no suction during the day) or the application of no external suction after a brief period of low suction (either in the operating room only or overnight for the first night, are reasonable).1 The senior author’s chest tube management has evolved, for nearly all patients having lobectomy, to 10 cm H2O of suction for the first night following surgery, then full-time water seal beginning the following morning regardless of air leak, unless the air leak is subjectively large. Patients who have air leaks undergo a chest radiograph 2 to 4 hours after water seal is initiated; they return to 10 cm H2O of suction only if there is a pneumothorax more than 20% in size, increasing subcutaneous emphysema, or clinical signs of failure of water seal (eg, new atrial fibrillation, dyspnea), all of which rarely occur. Pleural drainage systems In traditional chest drainage systems, air leaks are evaluated by detecting bubbles of air in the air leak chamber during forced expiratory maneuvers or cough. Using these systems, it can sometimes
be difficult to differentiate a true parenchymal air leak from evacuation of a small residual pleural space in the absence of an ongoing leak, and from a momentum leak, which is the appearance of leak created by momentum of the fluid column in patients who are able to generate an unusually strong cough. Although these momentum leaks typically are present only with coughing and not with normal tidal breathing, and often are observed only during the first several coughs a patient is asked to perform, these can cause confusion and delay chest tube removal and thus discharge to home. Different companies have produced objective systems capable of precisely measuring the amount of airflow through the chest tube. These devices express air leak in quantitative metrics collected over longer periods of time, rather than by observation of bubbles, and they have the capability to record and retrieve information that may ultimately make it possible to standardize chest tube management across different surgeons and institutions. These systems have been shown
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Burt & Shrager to significantly reduce the variability in deciding when to remove a chest drain31 and to decrease the duration of chest drain and hospital stay in randomized trials.32–34 Further, when using air leak grading systems, the amount of air leak identified in the early postoperative period can be effective in quantifying the risk of having persistent air leak in the later postoperative period and may predict which patients will not tolerate a no-externalsuction algorithm.25,35 Traditional pleural drainage systems deliver a fixed level of suction independent from the level of intrapleural pressure, which can be variable depending on several factors, including the column of fluid in the pleural drainage system tubing. Moreover, wide oscillations in the early postoperative pleural pressures are associated with a high risk of a PAL.36 Further, regulated pressure delivered by the digital pleural drainage devices, in which the intrapleural pressure is maintained at a consistent level within 0.1 cm H2O by a pressure sensor, is capable of stabilizing the pressure in the pleural cavity with minimal oscillations, and this may promote accelerated sealing of air leak.37 In a single-institution randomized trial, regulated suction ( 11 to 20 cm H2O) compared with regulated seal ( 2 cm H2O) showed that regulated seal is effective and as safe as regulated suction, with a trend toward decreased duration of air leak in the regulated suction group.38 A separate multicenter and international randomized trial of digital versus traditional drainage devices was recently completed. In patients undergoing anatomic resection, patients randomized to digital drainage systems had significantly shorter air leak duration, duration of chest tube placement, and postoperative lengths of stay.32 Chest tube removal Chest tubes are traditionally removed when an air leak has resolved and when the pleural fluid drainage is at an acceptable value to the thoracic surgeon, which, for many surgeons, has been estimated to be in the range of 250 to 350 mL per day. Regarding the volume of fluid drainage, there are now several studies that suggest that chest drains can be removed safely at much higher levels of effluent. Data from 2 separate institutions have recently shown that it is safe to remove chest tubes following pulmonary resection when drainage is as high as 450 to 500 mL per day, with exceedingly low rates of readmissions for symptomatic effusions.39,40 For patients who have a persistent air leak but are otherwise ready for hospital discharge (and without large or symptomatic pneumothorax on water seal), it has been shown that these patients can be discharged
home safely on an outpatient drainage device such as a Heimlich valve as early as postoperative day 4.39,41
Noninvasive Management of Prolonged Air Leak It is rare for aggressive reinterventions to be required to treat PALs. In several published studies, the incidence of reoperation or other aggressive reinterventions to treat this complication is less than 2%.1 The treatment strategy of watchful waiting, often as an outpatient, is largely successful. Approximately 95% of PALs that permit a no-external-suction algorithm resolve within a few weeks of operation with chest tube drainage alone, with only rare development of empyema.1 Heimlich valve For patients with no more than a small, stable, and asymptomatic pneumothorax on water seal, PALs can be managed in the outpatient setting using a 1-way valve attached to the drain. If necessary to differentiate true air leak from residual space evacuation, the patients can undergo a provocative clamping trial; most of these patients are able to safely have their chest tubes removed. A report by Cerfolio and colleagues42 on 199 patients discharged home with a persistent air leak and chest tube placed to a suctionless portable drainage device suggested that the air leak seals in the outpatient setting in almost all patients. For 9 patients with a persistent air leak after 2 weeks of outpatient management with a Heimlich valve, all patients had their chest tubes removed without sequela, some after a provocative clamping trial. If a period of watchful waiting for several weeks (we have waited as long as 4 weeks) is unsuccessful in treating a PAL, or if no external suction is not tolerated because of a larger leak, then the clinician must consider active interventions to mechanically seal the site of the leak. Most of these options are supported by expert consensus with variable amounts of published data. Pleurodesis and autologous blood patch If the residual lung is fully expanded, chemical pleurodesis with instillation via the thoracostomy tube of tetracycline, doxycycline, or talc can promote pleural symphysis and leak closure. These treatments all seem to be effective for pleurodesis in small cases series.43,44 An autologous blood patch is another simple and often effective treatment of PAL. Although some reports suggest an associated increased risk of intrathoracic infection (in 1 study, 1 of 10 patients developed empyema45), several prospective data
Air Leaks Following Pulmonary Resection suggest that an autologous blood patch has superior outcomes compared with the conservative management of PAL (summarized in Ref.46). Two of these studies were randomized trials that suggested that intrapleural instillation of autologous blood (120 mL) decreased the duration of PAL, time to chest tube removal, and time to hospital discharge.45 An additional randomized trial suggested that a 100-mL instillation of autologous blood decreased the time to air leak cessation more than a 50-mL instillation.47 We typically perform a blood patch by the sterile instillation of approximately 150 mL of blood freshly withdrawn into a 50-mL syringe from a large-bore intravenous line, and instilled immediately into the thoracostomy tube. Heparin is typically not used because it prevents the necessary intrathoracic clotting of blood that forms the patch, and we administer periprocedural antibiotics to minimize the risk of infection.
on. A bronchoscopy should be done to rule out a bronchial rather than a parenchymal fistula. If the residual lung is sufficiently normal, the leak can be restapled or oversewn with good results, and the approach can be thoracoscopic or open. Other options include thoracoscopic applications of topical sealants,53 with which we have no experience. Decortication of surrounding lung may be required to facilitate full lung expansion. Chemical pleurodesis or parietal pleurectomy/mechanical pleurodesis can be added when pleural apposition can be achieved.54 If a residual space is present, that space should be obliterated with either muscle or omental transposition, although most of the data on this are derived from the bronchopleural fistula literature. Following sublobar resection, completion lobectomy is necessary on rare occasions. Thoracoplasty or the creation of an open window can be considered under extreme circumstances.
Invasive Management of Prolonged Air Leak
SUMMARY
More invasive procedures are indicated to treat PALs if the more conservative measures discussed earlier fail. These interventions include pneumoperitoneum placed via an abdominal catheter, as described earlier (which is reported to be effective in treating PAL in some cases48,49), placement of endobronchial valves, and reoperation.
A variety of options are available to prevent and manage PALs. Intraoperative technical details are likely of greatest importance in reducing their incidence, and patients with substantial emphysema are at highest risk. Pleural tents and pneumoperitoneum created at the time of resection are helpful when residual spaces are likely; commercial buttresses and sealants have shown mixed results outside of severe emphysema and are expensive. Optimal postoperative management of chest tubes seems to include less than the traditional 20 cm H2O of external suction until cessation of air leak in most patients. Noninvasive approaches to resolve PALs (ie, watchful waiting with an outpatient Heimlich valve) are almost always effective, but invasive, nonsurgical interventions or surgical procedures are largely successful when required.
Endobronchial valves Unidirectional endobronchial valves, originally studied for treatment of emphysema, have emerged as a useful intervention for some patients with PAL. The early experiences of several centers have shown that bronchoscopic placement of these valves can be effective in some difficult cases of PAL. The source of an air leak is typically identified by the stepwise blocking of segmental and subsegmental bronchi by a balloon catheter while monitoring the size of the air leak in the pleural drainage device. Endobronchial 1-way valves deployed in the orifice or orifices of the segment or subsegments responsible for air leak may result in the improvement or cessation of PAL.50–52 Although these data are overall currently limited, these devices have received Humanitarian Device Exemption approval from the US Food and Drug Administration for this purpose. Surgical intervention Surgical reexploration is rarely required but must be considered when other approaches have failed. The choice of operation depends on whether a residual space is present, the quality of the remaining lung, and presence or absence of pleural space infection once surgery has been decided
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the clinical practice. Eur J Cardiothorac Surg 2009; 35(1):28–31. Pompili C, Detterbeck F, Papagiannopoulos K, et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. Ann Thorac Surg 2014;98(2):490–6 [discussion: 496–7]. Brunelli A, Salati M, Refai M, et al. Evaluation of a new chest tube removal protocol using digital air leak monitoring after lobectomy: a prospective randomised trial. Eur J Cardiothorac Surg 2010;37(1):56–60. Cerfolio RJ, Bryant AS. The benefits of continuous and digital air leak assessment after elective pulmonary resection: a prospective study. Ann Thorac Surg 2008;86(2):396–401. Cerfolio RJ, Bryant AS, Singh S, et al. The management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005;128(2):816–20. Brunelli A, Cassivi SD, Salati M, et al. Digital measurements of air leak flow and intrapleural pressures in the immediate postoperative period predict risk of prolonged air leak after pulmonary lobectomy. Eur J Cardiothorac Surg 2011;39(4):584–8. Brunelli A, Beretta E, Cassivi SD, et al. Consensus definitions to promote an evidence-based approach to management of the pleural space. A collaborative proposal by ESTS, AATS, STS, and GTSC. Eur J Cardiothorac Surg 2011;40(2):291–7. Brunelli A, Salati M, Pompili C, et al. Regulated tailored suction vs regulated seal: a prospective randomized trial on air leak duration. Eur J Cardiothorac Surg 2013;43(5):899–904. Cerfolio RJ, Bryant AS. Results of a prospective algorithm to remove chest tubes after pulmonary resection with high output. J Thorac Cardiovasc Surg 2008;135(2):269–73. Bjerregaard LS, Jensen K, Petersen RH, et al. Early chest tube removal after video-assisted thoracic surgery lobectomy with serous fluid production up to 500 ml/day. Eur J Cardiothorac Surg 2014;45(2): 241–6. McKenna RJ Jr, Mahtabifard A, Pickens A, et al. Fast-tracking after video-assisted thoracoscopic surgery lobectomy, segmentectomy, and pneumonectomy. Ann Thorac Surg 2007;84(5):1663–7 [discussion: 1667–8]. Cerfolio RJ, Minnich DJ, Bryant AS. The removal of chest tubes despite an air leak or a pneumothorax.
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Ann Thorac Surg 2009;87(6):1690–4 [discussion: 1694–6]. Kilic D, Findikcioglu A, Hatipoglu A. A different application method of talc pleurodesis for the treatment of persistent air leak. ANZ J Surg 2006;76(8): 754–6. Read CA, Reddy VD, O’Mara TE, et al. Doxycycline pleurodesis for pneumothorax in patients with AIDS. Chest 1994;105(3):823–5. Shackcloth MJ, Poullis M, Jackson M, et al. Intrapleural instillation of autologous blood in the treatment of prolonged air leak after lobectomy: a prospective randomized controlled trial. Ann Thorac Surg 2006;82(3):1052–6. Chambers A, Routledge T, Bille A, et al. Is blood pleurodesis effective for determining the cessation of persistent air leak? Interact Cardiovasc Thorac Surg 2010;11(4):468–72. Andreetti C, Venuta F, Anile M, et al. Pleurodesis with an autologous blood patch to prevent persistent air leaks after lobectomy. J Thorac Cardiovasc Surg 2007;133(3):759–62. Carbognani P, Spaggiari L, Solli PG, et al. Postoperative pneumoperitoneum for prolonged air leaks and residual spaces after pulmonary resections. J Cardiovasc Surg 1999;40(6):887–8. De Giacomo T, Rendina EA, Venuta F, et al. Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections. Ann Thorac Surg 2001;72(5):1716–9. Kovitz KL, French KD. Endobronchial valve placement and balloon occlusion for persistent air leak: procedure overview and new current procedural terminology codes for 2013. Chest 2013;144(2):661–5. Travaline JM, McKenna RJ Jr, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009;136(2):355–60. Firlinger I, Stubenberger E, Muller MR, et al. Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring. Ann Thorac Surg 2013;95(4):1243–9. Thistlethwaite PA, Luketich JD, Ferson PF, et al. Ablation of persistent air leaks after thoracic procedures with fibrin sealant. Ann Thorac Surg 1999; 67(2):575–7. Suter M, Bettschart V, Vandoni RE, et al. Thoracoscopic pleurodesis for prolonged (or intractable) air leak after lung resection. Eur J Cardiothorac Surg 1997;12(1):160–1.
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KEY POINTS Based on preoperative risk factors, selected patients should be considered for intraoperative techniques to minimize air leaks and the residual spaces that predispose to prolonged air leaks, including pleural tenting and pneumoperitoneum. There is insufficient evidence for the routine use of surgical sealants following pulmonary resection; we recommend buttressing staple lines in nonanatomic pulmonary resections for patients with moderate to severe emphysema (forced expiratory volume in 1 second <60% of predicted) to prevent prolonged air leaks. In postoperative patients with less than a large air leak and no more than a small pneumothorax, algorithms incorporating no applied external suction or alternating suction likely reduce the duration of air leak. Initial evaluation of digital drainage systems suggest that their use may result in shorter duration of air leak, duration of chest tube, and length of stay. Most prolonged alveolar air leaks resolve with time and tube drainage alone, and a trial of a few weeks of watchful waiting incorporating a Heimlich valve is reasonable in the outpatient setting.
Alveolar air leaks after pulmonary resection are a common problem in thoracic surgery. A variety of reports have shown that an air leak is present immediately on completion of a routine pulmonary resection in 28% to 60% of patients, after both lobectomies and lesser resections. On the morning of postoperative day 1, an air leak is present in 26% to 48% of patients; on the morning of postoperative day 2, an air leak is present in 22% to 24% of patients; and on the morning of postoperative day 4, an air leak is present in 8% of patients.1
A contemporary, practical definition of prolonged air leak (PAL) is an air leak that persists beyond postoperative day 5. This definition is used by the Society of Thoracic Surgeons database and represents a leak whose duration exceeds the average length of stay (LOS) for lobectomy. Several studies have found that PAL is associated with an increased rate of postoperative complications following routine pulmonary resection. Brunelli and colleagues2 reported an 8.2% to 10.4% rate of empyema in patients who had an air leak lasting more than 7 days, compared with a 0% to 1.1% in patients with lesser air leaks. Similarly,
Disclosures: Dr J.B. Shrager is a consultant for Maquet, Inc. a Division of Thoracic Surgery, Baylor College of Medicine, One Baylor Plaza, BCM 390, Houston, TX 77030, USA; b Division of Thoracic Surgery, Stanford Hospitals and Clinics, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building CV-207, Stanford, CA 94305, USA; c Division of Thoracic Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA * Corresponding author. Division of Thoracic Surgery, Stanford Hospitals and Clinics, Stanford University School of Medicine, 300 Pasteur Drive, Falk Building CV-207, Stanford, CA 94305. E-mail address: [email protected] Thorac Surg Clin 25 (2015) 411–419 http://dx.doi.org/10.1016/j.thorsurg.2015.07.002 1547-4127/15/$ – see front matter Published by Elsevier Inc.
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INTRODUCTION
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Burt & Shrager Varela and colleagues3 found that air leaks lasting at least 5 days postoperatively were associated with increased pulmonary morbidity, including atelectasis, pneumonia, or empyema. In the lung volume reduction surgery (LVRS) population, postoperative complications occur more often in patients experiencing air leak (57%) than in those who do not (30%).4 Several risk factors for PAL following pulmonary resection have been identified. The most consistently identified risk factor for PAL is chronic obstructive pulmonary disease (COPD). Preoperative tests reflecting the severity of COPD and that are associated with PAL include reduced postoperative predicted forced expiratory volume in 1 second (FEV1), FEV1 less than 79% of predicted, FEV1 less than 1.5 L, FEV1 less than 70%, and both FEV1 and forced vital capacity less than 70%.1 Other risk factors with proven associations with PAL include carbon monoxide diffusion in the lung less than 80%, presence of adhesions, upper lobectomy and bilobectomy, presence of a pneumothorax coinciding with an air leak, and steroid use.1
THERAPEUTIC OPTIONS AND CLINICAL OUTCOMES Intraoperative Prevention of Air Leaks Because PALs are common, clearly increase LOS, and likely cause associated complications, several surgical strategies have been developed to prevent them. The general principles underlying these surgical techniques involve an elimination of residual space and achieving apposition of the visceral pleura, either to the parietal pleura or to transposed tissue (Table 1). Other techniques include addressing pulmonary resection beds and staple lines with adhesives and/or buttressing material. Routine performance/use of these techniques is not advisable; not all patients are expected to benefit from these intraoperative adjuncts, which can be time consuming and/or costly. A careful selection of patients for such techniques should be based on underlying risk factors and probability of PAL and pleural space problems. For example, small or moderate residual spaces after pulmonary resection in many patients are physiologic and inconsequential; they resolve over time without ill effect. However, a large residual space in the context of a patient at high risk for air leak, which may result in infection of that space, can lead to a cascade of untoward events and morbidity. There are several intraoperative measures for preventing residual air spaces with which a thoracic surgeon should be familiar and many of
Table 1 Intraoperative procedures to manage residual thoracic air spaces
Anatomic Structure Parietal pleura
Visceral pleura Diaphragm Muscular chest wall
Osteotendinous chest wall Omentum
Intraoperative Procedure Pleural tent Pleurectomy or pleurodesis Adhesiolysis Decortication Pneumoperitoneum Phrenic nerve paralysis Intrathoracic transposition of muscle Rib resection at thoracotomy level Tailored thoracoplasty Omental transposition
these have randomized studies establishing their effectiveness. Lung mobilization Although less often a problem after sublobar resection compared with lobectomy, attaining pleural apposition without having to resort to high levels of suction seems to be an effective strategy for preventing PALs. There are several techniques that are commonly used to minimize residual space. Mobilization of all intrapleural adhesions and division of the inferior pulmonary ligament are the simplest of these, and should be routinely practiced because they are helpful. Similarly, decortication of the remaining lung, in rare instances and when required, may facilitate pleural apposition. Pleural tent Creation of an apical pleural tent at the time of upper lobectomy or upper bilobectomy (resection of upper and middle lobes) is a proven technique for decreasing PAL. A pleural tent is created by detachment of the parietal pleura from the endothoracic fascia, usually beginning at the level of the thoracotomy or one of the upper thoracoscopic port sites. The pleura is elevated circumferentially along the chest wall, being careful not to tear it. The resulting pleural tent falls directly onto the staple lines along the interlobar fissures. It compartmentalizes the chest cavity by separating the caudally located, fully drained space, which contains the residual lung, from the cranially located undrained space, which is allowed to fill
Air Leaks Following Pulmonary Resection with serum. Three randomized trials in patients undergoing lung resection have shown that pleural tenting performed at the time of lung resection decreases chest tube duration and mean hospital stay5; decreases incidence of postoperative air leak6; and decreases air leak duration, chest tube duration, length of hospital stay, and hospital costs.7
severe emphysema undergoing lobectomy. However, as far as we know, this is purely theoretic, because the sealants have never been studied in this population. However, the fact that 1 study shows substantially reduced air leaks in patients after LVRS on the side treated with a sealant versus the control side not treated with sealants is suggestive.15
Pneumoperitoneum Creation of pneumoperitoneum at the time of lower lobectomy or lower bilobectomy (resection of middle and lower lobes) has also been shown to decrease PAL, time of chest tube drainage, and LOS.8,9 This step can be accomplished with a catheter placed transdiaphragmatically (through a purse-string suture) during the chest procedure or through a catheter or Veress needle, placed transabdominally in a manner similar to placing a laparoscopic port. Transient diaphragmatic paralysis via injection of the phrenic nerve with a local anesthetic has been described and can serve a similar purpose.10
Staple-line buttressing The routine use of staple-line buttressing has also shown variable results. In severe emphysema (eg, LVRS), randomized data suggest that buttressing is effective for decreasing postoperative air leak and decreasing the duration of chest tube drainage and hospital stay.16,17 Less robust data are available for patients undergoing anatomic resection. For example, one prospective randomized trial was performed in which 80 patients, undergoing lobectomy or segmentectomy, were assigned to receive staple-line buttressing with pericardial strips or standard treatment. This trial showed no advantage of buttressing with regard to time to chest tube removal or hospital stay, and there was only a trend toward reduced duration of air leak.18 We recommend buttressing staple lines in nonanatomic pulmonary resections for patients with moderate to severe emphysema (FEV1<60% of predicted) to prevent PALs.1 In lobectomies (perhaps other than the horizontal fissure divided during right upper and middle lobectomies), the fissures are generally fairly thin and do not seem to require buttressing.
Surgical sealants A Cochrane Database Review has evaluated the use of surgical sealants for the prevention or reduction of postoperative air leaks following pulmonary resection. This review included 16 randomized trials and 1642 patients.11 Only 6 trials were able to show a significant reduction of postoperative air leaks by the use of sealants, and 3 trials showed a significant reduction in time to chest tube removal in the treatment group. These benefits (shown in a minority of trials) did not generally translate into reduced length of hospital stay, and we agree with the investigators of the Cochrane Review in not recommending routine use of these surgical sealants in patients undergoing pulmonary resection. A polymeric biodegradable hydrogel sealant (Progel) is the only sealant currently US Food and Drug Administration approved for intraoperative use during pulmonary resection. A randomized trial has suggested that intraoperative application of this product may reduce postoperative air leaks and result in 1less hospital day. However, Progel did not result in any difference in duration of chest tubes, so it is hard to attribute the reduced LOS to the product.12 We, and other investigators who have reviewed available data on lung sealants, have come to similar conclusions: that the current evidence does not support the routine use of these products in pulmonary resection.13,14 However, it is possible that sealants may eventually be shown to provide some measureable benefit in patients at high risk for PAL; for example, those with moderate to
Tissue transposition Intrathoracic transposition of muscle flaps can function to obliterate residual spaces and, similar to a pleural tent, can be used to partition the thoracic cavity (muscle tent). Muscle transposition should be considered at the time of initial operation in cases in which complex, infected residual spaces may be created following lung resection. Serratus anterior and latissimus dorsi flaps can be transferred together or separately into the chest. Preserving the thoracodorsal vascular pedicle, both of these muscles can be transposed through a window created in the chest wall by resection of a 5-cm segment of the second or third rib.19,20 In selected circumstances, the omentum can similarly be transposed into the thoracic cavity to fill the base of the chest,21 either through the anterior diaphragmatic muscle or through a substernal, mediastinal tunnel. Other techniques Other often-practiced, but less studied, techniques for intraoperative prevention of air leak include minimizing dissection within the fissures,
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Burt & Shrager minimizing inspiratory pressures when reinflating the lung, careful attention to avoid overlapping parenchymal staple lines, and closing the surgical stapler slowly in thick tissues. Another potentially useful approach is what has been termed the fissureless technique of lobectomy, which is often performed during videoassisted thoracoscopic surgery lobectomy. In a prospective study of lobectomy, 63 patients with incomplete or fused fissures were intraoperatively randomized to receive either the traditional technique or the fissureless technique to approach the fused fissures. The incidence of PAL was significantly higher among patients with incomplete or fused fissures, and a fissureless lobectomy technique that avoided dissection of the lung parenchyma over the pulmonary artery resulted in significantly decreased PAL and reduced hospital stay.22 Our opinion is that attention to these intraoperative details may be at least as effective as the commercially available sealants and other costly approaches.
Postoperative Management of Air Leaks During the initial management of a postoperative air leak, whether the leak originates from the alveoli through a peripheral tear in the visceral pleura (alveolar air leak) or from a bronchial structure (a bronchopleural fistula) can be hard to definitively determine. However, almost all postoperative air leaks are alveolar in origin, and the initial management therefore should be focused on treating this entity. Postoperative chest tube management Many thoracic surgeons prefer to manage postoperative chest tubes using external suction following lung resection in efforts to improve lung expansion, minimize residual pleural spaces, and to reduce the risk of system malfunction secondary to blood clotting. Other thoracic surgeons think that suction may prevent air leaks from sealing by increasing air flow through visceral pleural defects, and that air leaks are therefore more likely to seal with no applied external suction. A traditional practice is to place chest drains to 20 cm H2O suction after pulmonary resection and then to convert the tubes to water seal when there is no visible air leak. The early LVRS experience led many clinicians to question this traditional practice, with experience with these patients with severe emphysema suggesting that placing the chest tubes of patients having LVRS to the traditional 20 cm H2O of suction caused PALs and led to significant problems.23,24 Surgeons who have performed substantial numbers of LVRS procedures have no doubt that this is the case. This LVRS experience stimulated
surgeons to study whether a no–external-suction algorithm can reduce air leak and PAL after nonLVRS pulmonary resections as well. Six randomized trials have been published assessing the management of chest tubes with external suction compared with those with no external suction applied25–30 (Table 2). Three trials showed an advantage in duration of air leak, time to chest tube removal, and/or length of hospital stay for the early water seal modality.25,26,28 Two trials did not find a difference in these metrics.27,29 One trial found that external suction ( 15 cm H2O) reduced the duration of persistent air leak after anatomic lung resection compared with no external suction.30 Significant differences in study design of these 6 trials may have resulted, to some degree, in the variability of their results. These differences included differences in the degree of external suction in the suction arm ( 10, 15, 20 cm H2O), differences in the times at which the chest drains were placed to suction (in the operating room, on postoperative day 1, or by alternating suction and no suction algorithms), definitions of PAL, drainage systems (traditional versus leak meter systems, and portable systems that may better facilitate ambulation [discussed later]), study participants (all patients vs those with visible air leak only), resection type (anatomic resection and nonanatomic resections), as well as the use of chest radiographs to evaluate pneumothorax. For example, the only study that reported a benefit to external suction followed a different algorithm from the other studies: patients were randomized to no external suction or to 15 cm H2O on postoperative day 1, and subsequently all patients’ tubes were placed to Heimlich valve on postoperative day 3.30 We interpret the balance of evidence from these randomized trials to suggest that some version of reduced or part-time suction likely decreases the duration of air leak after pulmonary resection in most patients. However, the ideal algorithm remains uncertain. Although there is no high-level evidence available to date specifically in patients with severe emphysema, expert consensus and extensive clinical experience (in LVRS) suggest that patients with obstructive lung disease and an FEV1 less than 45% of predicted are optimally treated with no external suction applied in the absence of a large, symptomatic, or growing pneumothorax; progressive subcutaneous emphysema; or clinical deterioration. The traditional 20 cm H2O of suction is clearly counterproductive in these patients. For patients without severe emphysema, we think that available evidence suggest that either alternating suction (alternating 10 cm H2O of
Air Leaks Following Pulmonary Resection
Table 2 Randomized trials evaluating no external suction (NES) algorithms following pulmonary resection
Author
Algorithm
N
Resections
CXR Benefit of Evaluation NES
NES on POD 2 33 Lobectomy, Yes Cerfolio after 20 cm H2O sublobar et al,25 2001 NES after 20 cm 68 Lobectomy, Yes Marshall H2O while in OR sublobar et al,26 2002 145 Lobectomy No Brunelli et al,27 NES on POD 1 2004 after 20 cm H2O Brunelli et al,28 2005
Alphonso et al,29 2005
Leo et al,30 2013
Alternating 10 94 Lobectomy No cm H2O (day) and NES (night) vs full-time NES, after 10 cm H2O Immediate NES 239 Lobectomy, No sublobar
NES or 15 cm H2O on POD 1, all tubes to Heimlich valve on POD 3
500 Lobectomy, Yes sublobar
Yes Yes No
Yes
Comments Greater sealing of AL by POD 3 Reduced duration of AL Increased complications with NES Fewer PALs, shorter tube duration and LOS
Yes
No differences in PAL or tube duration but increased mobilization with NES Reduced PAL No (there duration with was a 15 cm H2O benefit suction in the to 15 cm anatomic H2O) resection subgroup
Abbreviations: AL, air leak; CXR, chest radiograph; OR, operating room; PAL, prolonged air leak; POD, postoperative day. Data from Refs.25–30
suction at night with no suction during the day) or the application of no external suction after a brief period of low suction (either in the operating room only or overnight for the first night, are reasonable).1 The senior author’s chest tube management has evolved, for nearly all patients having lobectomy, to 10 cm H2O of suction for the first night following surgery, then full-time water seal beginning the following morning regardless of air leak, unless the air leak is subjectively large. Patients who have air leaks undergo a chest radiograph 2 to 4 hours after water seal is initiated; they return to 10 cm H2O of suction only if there is a pneumothorax more than 20% in size, increasing subcutaneous emphysema, or clinical signs of failure of water seal (eg, new atrial fibrillation, dyspnea), all of which rarely occur. Pleural drainage systems In traditional chest drainage systems, air leaks are evaluated by detecting bubbles of air in the air leak chamber during forced expiratory maneuvers or cough. Using these systems, it can sometimes
be difficult to differentiate a true parenchymal air leak from evacuation of a small residual pleural space in the absence of an ongoing leak, and from a momentum leak, which is the appearance of leak created by momentum of the fluid column in patients who are able to generate an unusually strong cough. Although these momentum leaks typically are present only with coughing and not with normal tidal breathing, and often are observed only during the first several coughs a patient is asked to perform, these can cause confusion and delay chest tube removal and thus discharge to home. Different companies have produced objective systems capable of precisely measuring the amount of airflow through the chest tube. These devices express air leak in quantitative metrics collected over longer periods of time, rather than by observation of bubbles, and they have the capability to record and retrieve information that may ultimately make it possible to standardize chest tube management across different surgeons and institutions. These systems have been shown
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Burt & Shrager to significantly reduce the variability in deciding when to remove a chest drain31 and to decrease the duration of chest drain and hospital stay in randomized trials.32–34 Further, when using air leak grading systems, the amount of air leak identified in the early postoperative period can be effective in quantifying the risk of having persistent air leak in the later postoperative period and may predict which patients will not tolerate a no-externalsuction algorithm.25,35 Traditional pleural drainage systems deliver a fixed level of suction independent from the level of intrapleural pressure, which can be variable depending on several factors, including the column of fluid in the pleural drainage system tubing. Moreover, wide oscillations in the early postoperative pleural pressures are associated with a high risk of a PAL.36 Further, regulated pressure delivered by the digital pleural drainage devices, in which the intrapleural pressure is maintained at a consistent level within 0.1 cm H2O by a pressure sensor, is capable of stabilizing the pressure in the pleural cavity with minimal oscillations, and this may promote accelerated sealing of air leak.37 In a single-institution randomized trial, regulated suction ( 11 to 20 cm H2O) compared with regulated seal ( 2 cm H2O) showed that regulated seal is effective and as safe as regulated suction, with a trend toward decreased duration of air leak in the regulated suction group.38 A separate multicenter and international randomized trial of digital versus traditional drainage devices was recently completed. In patients undergoing anatomic resection, patients randomized to digital drainage systems had significantly shorter air leak duration, duration of chest tube placement, and postoperative lengths of stay.32 Chest tube removal Chest tubes are traditionally removed when an air leak has resolved and when the pleural fluid drainage is at an acceptable value to the thoracic surgeon, which, for many surgeons, has been estimated to be in the range of 250 to 350 mL per day. Regarding the volume of fluid drainage, there are now several studies that suggest that chest drains can be removed safely at much higher levels of effluent. Data from 2 separate institutions have recently shown that it is safe to remove chest tubes following pulmonary resection when drainage is as high as 450 to 500 mL per day, with exceedingly low rates of readmissions for symptomatic effusions.39,40 For patients who have a persistent air leak but are otherwise ready for hospital discharge (and without large or symptomatic pneumothorax on water seal), it has been shown that these patients can be discharged
home safely on an outpatient drainage device such as a Heimlich valve as early as postoperative day 4.39,41
Noninvasive Management of Prolonged Air Leak It is rare for aggressive reinterventions to be required to treat PALs. In several published studies, the incidence of reoperation or other aggressive reinterventions to treat this complication is less than 2%.1 The treatment strategy of watchful waiting, often as an outpatient, is largely successful. Approximately 95% of PALs that permit a no-external-suction algorithm resolve within a few weeks of operation with chest tube drainage alone, with only rare development of empyema.1 Heimlich valve For patients with no more than a small, stable, and asymptomatic pneumothorax on water seal, PALs can be managed in the outpatient setting using a 1-way valve attached to the drain. If necessary to differentiate true air leak from residual space evacuation, the patients can undergo a provocative clamping trial; most of these patients are able to safely have their chest tubes removed. A report by Cerfolio and colleagues42 on 199 patients discharged home with a persistent air leak and chest tube placed to a suctionless portable drainage device suggested that the air leak seals in the outpatient setting in almost all patients. For 9 patients with a persistent air leak after 2 weeks of outpatient management with a Heimlich valve, all patients had their chest tubes removed without sequela, some after a provocative clamping trial. If a period of watchful waiting for several weeks (we have waited as long as 4 weeks) is unsuccessful in treating a PAL, or if no external suction is not tolerated because of a larger leak, then the clinician must consider active interventions to mechanically seal the site of the leak. Most of these options are supported by expert consensus with variable amounts of published data. Pleurodesis and autologous blood patch If the residual lung is fully expanded, chemical pleurodesis with instillation via the thoracostomy tube of tetracycline, doxycycline, or talc can promote pleural symphysis and leak closure. These treatments all seem to be effective for pleurodesis in small cases series.43,44 An autologous blood patch is another simple and often effective treatment of PAL. Although some reports suggest an associated increased risk of intrathoracic infection (in 1 study, 1 of 10 patients developed empyema45), several prospective data
Air Leaks Following Pulmonary Resection suggest that an autologous blood patch has superior outcomes compared with the conservative management of PAL (summarized in Ref.46). Two of these studies were randomized trials that suggested that intrapleural instillation of autologous blood (120 mL) decreased the duration of PAL, time to chest tube removal, and time to hospital discharge.45 An additional randomized trial suggested that a 100-mL instillation of autologous blood decreased the time to air leak cessation more than a 50-mL instillation.47 We typically perform a blood patch by the sterile instillation of approximately 150 mL of blood freshly withdrawn into a 50-mL syringe from a large-bore intravenous line, and instilled immediately into the thoracostomy tube. Heparin is typically not used because it prevents the necessary intrathoracic clotting of blood that forms the patch, and we administer periprocedural antibiotics to minimize the risk of infection.
on. A bronchoscopy should be done to rule out a bronchial rather than a parenchymal fistula. If the residual lung is sufficiently normal, the leak can be restapled or oversewn with good results, and the approach can be thoracoscopic or open. Other options include thoracoscopic applications of topical sealants,53 with which we have no experience. Decortication of surrounding lung may be required to facilitate full lung expansion. Chemical pleurodesis or parietal pleurectomy/mechanical pleurodesis can be added when pleural apposition can be achieved.54 If a residual space is present, that space should be obliterated with either muscle or omental transposition, although most of the data on this are derived from the bronchopleural fistula literature. Following sublobar resection, completion lobectomy is necessary on rare occasions. Thoracoplasty or the creation of an open window can be considered under extreme circumstances.
Invasive Management of Prolonged Air Leak
SUMMARY
More invasive procedures are indicated to treat PALs if the more conservative measures discussed earlier fail. These interventions include pneumoperitoneum placed via an abdominal catheter, as described earlier (which is reported to be effective in treating PAL in some cases48,49), placement of endobronchial valves, and reoperation.
A variety of options are available to prevent and manage PALs. Intraoperative technical details are likely of greatest importance in reducing their incidence, and patients with substantial emphysema are at highest risk. Pleural tents and pneumoperitoneum created at the time of resection are helpful when residual spaces are likely; commercial buttresses and sealants have shown mixed results outside of severe emphysema and are expensive. Optimal postoperative management of chest tubes seems to include less than the traditional 20 cm H2O of external suction until cessation of air leak in most patients. Noninvasive approaches to resolve PALs (ie, watchful waiting with an outpatient Heimlich valve) are almost always effective, but invasive, nonsurgical interventions or surgical procedures are largely successful when required.
Endobronchial valves Unidirectional endobronchial valves, originally studied for treatment of emphysema, have emerged as a useful intervention for some patients with PAL. The early experiences of several centers have shown that bronchoscopic placement of these valves can be effective in some difficult cases of PAL. The source of an air leak is typically identified by the stepwise blocking of segmental and subsegmental bronchi by a balloon catheter while monitoring the size of the air leak in the pleural drainage device. Endobronchial 1-way valves deployed in the orifice or orifices of the segment or subsegments responsible for air leak may result in the improvement or cessation of PAL.50–52 Although these data are overall currently limited, these devices have received Humanitarian Device Exemption approval from the US Food and Drug Administration for this purpose. Surgical intervention Surgical reexploration is rarely required but must be considered when other approaches have failed. The choice of operation depends on whether a residual space is present, the quality of the remaining lung, and presence or absence of pleural space infection once surgery has been decided
REFERENCES 1. Singhal S, Ferraris VA, Bridges CR, et al. Management of alveolar air leaks after pulmonary resection. Ann Thorac Surg 2010;89(4):1327–35. 2. Brunelli A, Xiume F, Al Refai M, et al. Air leaks after lobectomy increase the risk of empyema but not of cardiopulmonary complications: a case-matched analysis. Chest 2006;130(4):1150–6. 3. Varela G, Jimenez MF, Novoa N, et al. Estimating hospital costs attributable to prolonged air leak in pulmonary lobectomy. Eur J Cardiothorac Surg 2005;27(2):329–33. 4. DeCamp MM, Blackstone EH, Naunheim KS, et al. Patient and surgical factors influencing air leak after lung
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