ReviewManagement of Alveolar Air Leaks After Pulmonary Resection
Section snippets
Material and Methods
PubMed was searched for terms including “air leak,” “subcutaneous emphysema,” “pneumothorax,” “bronchopleural fistula,” “chest tube,” “thoracostomy,” “suction,” “water seal,” “pleurodesis,” and “Heimlich.” We reviewed the abstracts of these articles and then chose to critically analyze only those publications that addressed postoperative alveolar air leak management. During the review of these articles, if there was a reference that was not captured on the initial literature search but appeared
Definitions
For the purposes of this review, the phrase “air leak” refers to any leakage of air from the lung that is identified by noting bubbles in a chest drainage system, progressive subcutaneous emphysema, or expanding pneumothorax.
During the initial management of a postoperative air leak, whether the leak originates from the alveoli through a peripheral tear in the visceral pleura (ie, an alveolar air leak) or whether it originates from bronchial structures (ie, a bronchopleural fistula) is unclear.
Incidence of Air Leaks
The presence or absence of air leaks have been recorded at different postoperative time points in different studies. Several studies show an air leak to be present immediately at the completion of an operation in 28% to 60% of patients who undergo routine pulmonary resections, including both lobectomies and lesser resections [4, 5, 6, 7, 8]. On the morning of POD 1, an air leak is present in 26% to 48% of patients [9, 10]; on the morning of POD 2, an air leak is present in 22% to 24% [2, 9];
Clinical Implications of Prolonged Air Leaks
Several studies find that PAL increases complication rates after routine pulmonary resection [15, 20]. Brunelli and colleagues [20] found an 8.2% to 10.4% rate of empyema in patients with air leak lasting more than 7 days versus a rate of only 0% to 1.1% in patients with lesser air leaks. However, these authors found no difference between the PAL patients and others in the rate of other cardiopulmonary complications. Varela and colleagues [15] found that air leak lasting at least 5 days was
Risk Factors for Prolonged Air Leaks
Preoperative or intraoperative factors convincingly associated with PAL after routine lung resection are summarized in Table 1. The most consistently identified risk factor for PAL is chronic obstructive lung disease. There is a strong positive correlation between degree of emphysema and risk of air leak and PAL. Preoperative tests that reflect severity of chronic obstructive lung disease and are associated with PAL include postoperative predicted FEV1 [10], FEV1 < 79% predicted [22], FEV1 <
Postoperative Management of Routine (Nonprolonged) Air Leaks
Despite the absence of high level evidence to support the practice, we believe that most surgeons place chest drains to −20 cm H2O suction after most pulmonary resections, converting the tubes to water seal only when there is no visible air leak. In the early LVRS experience, this practice was questioned (ie, two studies suggest that placing LVRS patients' chest tubes to the traditional −20 cm suction might actually prolong air leaks [25, 26]). This degree of suction is not usually required to
Postoperative Management of Prolonged Air Leaks
As previously discussed, a variety of definitions have been used for PAL. The authors believe that a contemporary, practical, and operational definition of PAL is an air leak lasting beyond POD 5.
It is rare that aggressive reinterventions are required to treat PALs. In several published series, including more than 100 patients with PALs, the incidence of reoperation or other aggressive reintervention to treat this complication is less than 2% [13, 16, 23, 28, 29, 30, 31]. By far the most common
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