MANAGEMENT OF Presented by Nader Saad

PERSISTENT AIR LEAKS

OUTLINE
•Alveolar-pleural fistulas causing persistent air leaks (PALs) are associated with
prolonged hospital stays and high morbidity.
•Prior guidelines recommend surgical repair as the gold standard for treatment
•This review describes :
•Brief history of treatment guidelines for PALs.
•Novel treatment options.
•Detailed description of treatment options including postprocedural adverse events.
INTRODUCTI
ON
•An alveolar-pleural fistula is a
communication between the alveoli
and the pleural space. This
connection will lead to the
development of a pneumothorax.
•Persistent flow of air from the lung
parenchyma to the pleural space and
worsening of the pneumothorax.
•Once a chest tube is inserted, air
bubbling into the chest drainage
system indicates an air leak.
INTRODUCTION
•Majority of pneumothoraces resolve with thoracostomy tube drainage, many
continue days after the lung injury.
•If an air leak lasts > 5 to 7 days, it is termed a persistent air leak (PAL).
A PAL is commonly caused by :
1. Secondary spontaneous pneumothorax
2. Pulmonary infections
3. Complications of mechanical ventilation following chest trauma or pulmonary
surgery.
 Cerfolio classification:

QUANTIF
YING THE
SEVERITY
OF PALS
QUANTIFYING THE SEVERITY
OF PALS
•Air leak meter :
• Measured in columns from 1 to 7.
•The higher the numbered column through which bubbling occurs, the larger the air
leak.
•Digital chest drainage systems
•Allow direct quantitation of flow through the drainage system.
•Display the flow (in mL/min) along with the pleural pressure difference (maximum –
minimum pleural pressure) in real time.
•In general, once the air leak is < 20 mL/min, a chest tube can be safely removed.
Digital chest drainage system Air leak meter
INCIDENCE OF PERSISTENT
AIR LEAKS
•PALs are common after thoracic surgery.
•In patients undergoing lobectomies:
•The main issue with PALs is inadequate parenchyma to fill the hemithorax after lung
resection rather than collapsed lung.
•In patients undergoing LVRS: Incidence of PAL of 46% at 7 days post LVRS.
•The incidence of PALs is higher following LVRS (24%-46% incidence) when
compared with lobectomies (8.3%) and wedge resections (3.3%).
 RISK FACTORS FOR THE
DEVELOPMENT OF PAL
In patients undergoing lobectomy: In a prospective study of patients
following VATS for spontaneous
•COPD pneumothorax:
1. PAL was more common in
•History of smoking
patients with underlying lung
•Diabetes mellitus disease (31.3% vs 3.8%)
2. Increased age
•Chronic steroid use 3. Larger bullae diameter.
In patients post LVRS:
•Lower DLCO and lower FEV1
•Marked pleural adhesions noted during surgery
•Upper lobe/diffuse emphysema VS Lower lobe-predominant emphysema
In patients undergoing either LVRS or lobectomy ; PAL may not have an impact on
mortality.
Patients with a PAL had increased complications :
•ICU readmission Pneumonia Longer hospital stay
MANAGEMENT STRATEGIES

•The 2001 American College of Chest Physicians consensus statement on

spontaneous pneumothorax recommends thoracic surgical consultation if the air-leak
persists beyond 4 days, and they recommend medical pleurodesis if the patient is not
a surgical candidate
•The most recent British Thoracic Society pleural disease guideline recommend
surgical consultation if the air-leak persists beyond 48 hours. In patients who are
medically inoperable they recommend chemical pleurodesis or chest tube with one-
way flutter valve as alternatives
TREATMENT OPTIONS

•Historically , conservative management with prolonged chest tube drainage was the
treatment of choice.
•Attempts with sealants, Watanabe spigots, metal coils, alcohol sclerosis of the
airways, and many other interventions have been reported; all were anecdotal with
variable success .
•Chemical pleurodesis, autologous blood patch pleurodesis, and most recently,
endoscopically placed “one-way” valves to temporarily “plug” the airway have been
successful.
CONSERVATIVE
MANAGEMENT
•Conservative management of a PAL generally consists of chest tube drainage and
observation. There is not a current consensus on whether or not placing the chest
tube to suction delays the time needed for the fistulous tract to heal.
•Some authors contend that water seal rather than active suction promotes healing of
the alveolar-pleural fistula in pneumothorax by decreasing flow of air through the
defect and thereby improving apposition of the lung tissue
•Others believe that applying suction removes air from the pleural space at a rate
greater than that of air leakage via the visceral pleural defect, promoting apposition
between the visceral and parietal pleura thus enhancing healing
CONSERVATIVE
MANAGEMENT
•There are three major factors to consider when initially evaluating an air leak:
Volume, Duration, and Trend of the leak.
•In the absence of a bronchopleural fistula, postoperative air leaks will resolve over time,
even if that time involves weeks.
•In patients with air leaks are receiving positive-pressure ventilation:
•Early liberation from mechanical ventilation are ideal, as positive pressure may worsen the
size of the air leak and impair the ability to heal.
While the patient is receiving positive-pressure ventilation; Reducing the inspiratory
time, end-expiratory pressure, and tidal volume can help diminish the air leak.
•this question with differing results. There still is not a consensus as to “on or off” suction
for management.
PLACING THE CHEST TUBE TO
WATER SEAL
•A randomized controlled trial compared placing the chest tube to suction 1 day after
pulmonary resection vs placing the chest tube to water seal.
•This trial showed a statistically significant advantage by postoperative day 3 in those
air leaks placed to water seal rather than suction.
•In the patients who had been randomized to placing the chest tube to suction, once
the chest tube was placed to water seal (crossover portion of the study), the air leak
resolved within 1 day in 13 of the 14 patients.
DISCHARGE HOME WITH A
ONE-WAY VALVE
•A study of 107 patients post-LVRS for emphysema, 25 patients experienced a prolonged air leak that
lasted > 5 days.
•Each patient with a PAL received a Heimlich valve to facilitate earlier hospital discharge, no matter
the size of the air leak.
•The Heimlich valve shortened hospital stay by 46%.
•Only one of the 25 patients required readmission for subcutaneous emphysema that resolved with
placing the chest tube drainage to suction.
•Conclusion:
•This small case-control trial demonstrated the safety of one-way valves and outpatient follow-up for
PALs.
DISCHARGE HOME WITH A
ONE-WAY VALVE
Another study by Cerfolio et al showed the safety of chest tube removal if a PAL
remained after the patient was discharged home with a Heimlich valve, as long as the
patient was asymptomatic ,without subcutaneous emphysema and the
pneumothorax had not increased in size.
HEIMLICH
VALVE
 SURGICAL MANAGEMENT OF
PAL
Surgical management of PAL has long been the mainstay of therapy in those patients in whom air
leaks do not resolve using conservative means.
A number of surgical approaches have been described:
•The reported rate of successful surgical treatment of postoperative PAL is between 80% and 95%
•For air leaks after secondary spontaneous pneumothorax, surgical management includes
resection of any blebs, bullae, or visible abnormalities of the visceral pleura as well as
mechanical and/or chemical pleurodesis to achieve pleural symphysis
•Both VATS and Open Thoracotomy are effective.
•Recurrence rates for secondary spontaneous pneumothorax with PAL are slightly lower with
Thoracotomy than VATS, but the morbidity of thoracotomy is higher
•Mortality of surgical treatment of PAL is low, but morbidity is significant
CHEMICAL PLEURODESIS

Sclerosants are chemicals that cause an inflammatory response and, when

administered into the pleural space, allow for sealing of the pleural space, cessation of
an air leak, and prevention of recurrent pneumothorax.
Common sclerosing agents inclue :
Talc, tetracycline, bleomycin, and OK-432 (mixture of a low-virulence strain
of Streptococcus pyogenes incubated with benzylpenicillin).
CHEMICAL PLEUDESIS

•Medical chemical pleurodesis is recommended by existing guidelines for

spontaneous pneumothorax for recurrence prevention in those patients with PAL
who are not candidates for surgery
•Evidence of its effectiveness is mixed
•The largest study to date was published by Light and colleagues in 1990. They
randomized 229 patients to receive either intrapleural tetracycline or usual care.
Results showed that pleurodesis with tetracycline did reduce the recurrence rate of
spontaneous pneumothorax overall. However, analysis of the subset of 39 patients
who had PAL at the time of randomization showed no benefit of tetracycline
pleurodesis in those patients with air leak
CHEMICAL PLEUDESIS

•Chemical pleurodesis should be performed only if there is no or only a small residual

pneumothorax when the chest tube is placed on water seal. Otherwise, chemical
pleurodesis should not be performed, as it may result in a lung that is unable to re-
expand.
•Complications of chemical pleurodesis include chest pain, fever, ARDS, and
empyema (incidence reported 1%)
AUTOLOGOUS BLOOD PATCH
PLEURODESIS
• Blood pleurodesis, or “blood patch”, is a technique in which the patient’s own venous blood is instilled
into the pleural space where it coagulates, sealing the site of the air leak
• A recent review of 10 studies prior to 2010 found an overall success rate of 92% to 93% in patients
with PALs following pulmonary resection or spontaneous pneumothorax.
• Typically, 50 to 200 mL of peripheral venous blood is taken from the patient’s arm and injected under
sterile conditions through the chest tube into the pleural cavity.
• The chest tube is then flushed with 10 mL of normal saline and either clamped or more often elevated
relative to the position of the patient and the pleural vacuum drain to allow air to escape while keeping
the infused blood inside the pleural space
• Reported complications are rare but include tension pneumothorax secondary to an obstructing clot in
the chest tube, pleuritis, and empyema (incidence reported 0%-9%)
BLOOD
PATCH
PLEUROD
ESIS
BRONCHOSCOPIC MANAGEMENT OF PAL
LOCALIZING THE AIR LEAK

•The most commonly used method for localization is selective balloon bronchial
occlusion
•Done under general anesthesia with an endotracheal tube to keep the system air- tight .
•Then a balloon catheter is advanced through the working channel of the flexible
bronchoscope and positioned initially in a proximal airway ipsilateral to the air leak.
•Once the balloon is inflated and the selected bronchus is fully occluded, the chest drain
is observed for 2–3 minutes for evidence that the leak is decreasing.
•If the air leak lessens or stops with occlusion of the first bronchus, the balloon is
deflated and then positioned in each more distal segment until the leak is fully
localized.
BRONCHOSCOPIC SEALANTS,
SCLEROSANTS, AND IMPLANTS FOR PAL

•Among the sealants : Reported are fibrin or fibrin glue , cyanoacrylate glue , oxidized cellulose.
•Our review found no comparative studies, but reported complications are infrequent.
Sclerosants :
•Have also been used to treat PAL by causing inflammation and fibrosis at the site of the tissue
defect.
•Reported sclerosants include ethanolamine, ethanol , and tetracycline Endobronchial implants
have also been used to palliate air leaks.
•Endobronchial placement of vascular embolization coils, with and without the addition of
sealant, has also been used to treat PAL with limited success
•Overall results for sealants, sclerosants, and implants have been mixed, and larger comparative
studies are needed to truly determine their optimal use.
ENDOBRONCHIAL/
INTRABRONCHIAL VALVES
Endobronchial valves (EBVs) and intrabronchial valves (IBVs) are one-way valves placed
with a flexible bronchoscope in segmental or subsegmental bronchi to limit airflow to
portions of the lungs distal to the placed valve while allowing mucous and air movement
in the proximal direction.
Two case series by Travaline et al and Gillespie et al have detailed the use of EBVs
and IBVs for PALs.
Gillespie et al described a series of seven patients with severe PALs that persisted for a
median of 4 weeks after usual therapeutic measures failed. With IBV placement, the air
leak improved in all patients and resulted in hospital discharge within 3 days in four of
seven patients.
ENDOBRONCHIAL/
INTRABRONCHIAL VALVES
In a multicenter study with 40 patients, Travaline et al showed the EBV Zephyr
(PulmonX) to be an effective minimally invasive device for treating PALs.
Following valve placement, the air leaks resolved or decreased in 37 patients
(92.5%), with 19 patients (47.5%) having complete resolution of the air leak.
Six of 40 patients experienced complications including :
1. Valve malposition and expectoration
2. Pneumonia
3. Moderate oxygen desaturation
4. MRSA colonization.
RESULTS
A limitation of these five studies is the lack of a control group. Currently, the Valves
Against Standard Therapy (VAST) study is ongoing.
Based on these case series as well as multiple case reports, placement of IBVs for
PALs has been successful in some patients in whom conservative treatment has
failed or who are poor surgical candidates.
CONCLUSIONS

•Conservative treatment with chest drainage and observation is effective most of the
time. When it fails, surgical management should be considered.
•Unfortunately, the morbidity of surgery is significant and many patients with severe
lung disease are poor operative candidates.
•For this specific group of patients and for those who do not desire surgery,
nonsurgical treatment should be offered. Pleurodesis with medicines or blood can be
used, but controlled studies are lacking.
•The most promising bronchoscopic treatment currently is the placement of one- way
valves within the airways leading to the area of the lung from where the PAL is
originating. Early reports have demonstrated success as well as a low rate of
complications,