Review
Management of Alveolar Air Leaks After Pulmonary Resection

https://doi.org/10.1016/j.athoracsur.2009.09.020Get rights and content

Air leaks are a common problem after pulmonary resection and can be a source of significant morbidity and mortality. Air leaks are associated with prolonged hospital stays, and infectious and cardiopulmonary complications, and they occasionally require reoperation. Despite reasonably robust literature on the topic, the optimal approaches to manage postoperative air leaks remain controversial. We used available literature and expert consensus to formulate suggestions regarding the preferred approaches to both routine and prolonged alveolar air leaks. This review summarizes our findings.

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

References (65)

  • M.E. Kreider et al.

    Complications of video-assisted thoracoscopic lung biopsy in patients with interstitial lung disease

    Ann Thorac Surg

    (2007)
  • M.H. Cho et al.

    Mechanical ventilation and air leaks after lung biopsy for acute respiratory distress syndrome

    Ann Thorac Surg

    (2006)
  • A. Brunelli et al.

    Air leaks after lobectomy increase the risk of empyema but not of cardiopulmonary complications: a case-matched analysis

    Chest

    (2006)
  • R.J. Cerfolio

    Chest tube management after pulmonary resection

    Chest Surg Clin N Am

    (2002)
  • J.D. Cooper et al.

    Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema

    J Thorac Cardiovasc Surg

    (1996)
  • A. Brunelli et al.

    Alternate suction reduces prolonged air leak after pulmonary lobectomy: a randomized comparison versus water seal

    Ann Thorac Surg

    (2005)
  • R.J. McKenna et al.

    Use of the Heimlich valve to shorten hospital stay after lung reduction surgery for emphysema

    Ann Thorac Surg

    (1996)
  • R.B. Ponn et al.

    Outpatient chest tube management

    Ann Thorac Surg

    (1997)
  • R.J. McKenna et al.

    Fast-tracking after video-assisted thoracoscopic surgery lobectomy, segmentectomy, and pneumonectomy

    Ann Thorac Surg

    (2007)
  • K.M. Rieger et al.

    Postoperative outpatient chest tube management: initial experience with a new portable system

    Ann Thorac Surg

    (2007)
  • P.A. Kirschner

    “Provocative clamping” and removal of chest tubes despite persistent air leak

    Ann Thorac Surg

    (1992)
  • C.A. Read et al.

    Doxycycline pleurodesis for pneumothorax in patients with AIDS

    Chest

    (1994)
  • A. Droghetti et al.

    Autologous blood patch in persistent air leaks after pulmonary resection

    J Thorac Cardiovasc Surg

    (2006)
  • M.J. Shackcloth 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)
  • H. Yokomise et al.

    Autoblood plus OK432 pleurodesis with open drainage for persistent air leak after lobectomy

    Ann Thorac Surg

    (1998)
  • R. Dumire et al.

    Autologous “blood patch” pleurodesis for persistent pulmonary air leak

    Chest

    (1992)
  • T. De Giacomo et al.

    Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections

    Ann Thorac Surg

    (2001)
  • J.R. Handy et al.

    Pneumoperitoneum to treat air leaks and spaces after a lung volume reduction operation

    Ann Thorac Surg

    (1997)
  • M. Torre et al.

    Nd-YAG laser pleurodesis via thoracoscopyEndoscopic therapy in spontaneous pneumothorax Nd-YAG laser pleurodesis

    Chest

    (1994)
  • P.A. Thistlethwaite et al.

    Ablation of persistent air leaks after thoracic procedures with fibrin sealant

    Ann Thorac Surg

    (1999)
  • L.M. Backhus et al.

    Pleural space problems after living lobar transplantation

    J Heart Lung Transplant

    (2005)
  • J.S. Ferguson et al.

    Closure of a bronchopleural fistula using bronchoscopic placement of an endobronchial valve designed for the treatment of emphysema

    Chest

    (2006)
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