Response

Abstract

We thank Drs Eberlein, Reed, Redwan, and Bolukbas for their insightful comments on our recent article in CHEST regarding the relationship between collateral ventilation and persistent air leaks (PALs).1Dugan K.C. Laxmanan B. Murgu S. Hogarth D.K. Management of persistent air leaks.Chest. 2017; 152: 417-423Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar As they pointed out in their letter, emphysema has been identified as a significant risk factor for the development of PALs following surgery. Indeed, collateral ventilation is more prevalent in patients with emphysema and incomplete fissures and would not only put these patients at risk for a PAL but likely make management more challenging.2Terry P.B. Traystman R.J. Newball H.H. et al.Collateral ventilation in man.N Engl J Med. 1978; 298: 10-15Crossref PubMed Scopus (144) Google Scholar When endobronchial valves (EBVs) have been used for bronchoscopic lung volume reduction, the researchers found a lack of significant improvement in patients with incomplete fissures, arguing that collateral ventilation can complicate EBV placement by allowing air to bypass the pathway of greater resistance.3Sciurba F.C. Ernst A. Herth F.J. et al.A randomized study of endobronchial valves for advanced emphysema.N Engl J Med. 2010; 363: 1233-1244Crossref PubMed Scopus (638) Google Scholar Anecdotally, as hypothesized in the letter, we have seen evidence of this phenomenon when placing EBVs in patients with emphysema and a PAL. Typically, occluding only one airway does not resolve the air leak (despite proper localization using the endobronchial balloon technique), and multiple valves may need to be placed, sometimes in more than one lobe. Thus, on average, three valves are typically required to control each PAL.4Travaline J.M. McKenna R.J. De Giacomo T. Treatment of persistent pulmonary air leaks using endobronchial valves.Chest. 2009; 136: 355-360Abstract Full Text Full Text PDF PubMed Scopus (152) Google Scholar The Valves Against Standard Therapy (VAST) study is ongoing, comparing EBVs with standard care for PALs.5Spiration Valves Against Standard Therapy (VAST). 2015. NLM identifier NCT02382614. https://clinicaltrials.gov/ct2/show/NCT02382614. Accessed June 13, 2017.Google Scholar We hope that this study will allow a further analysis of fissure integrity (as assessed by using chest CT scans) and the success of EBVs for patients experiencing PALs. Management of Persistent Air LeaksCHESTVol. 152Issue 2PreviewAlveolar-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, albeit it is a solution with limited success. In patients who have recently undergone thoracic surgery or in whom surgery would be contraindicated based on the severity of illness, there has been a lack of treatment options. This review describes a brief history of treatment guidelines for PALs. Full-Text PDF Persistent Air LeaksCHESTVol. 152Issue 2PreviewWe read with great interest the review by Dugan et al1 published in this issue of CHEST (August 2017) on the management of persistent air leaks (PALs). The authors note that the highest incidence of PALs occurred in patients undergoing lung volume reduction surgery for emphysema (24%-46%), followed by patients undergoing lobectomies (8.6%). Notably, clinical factors associated with emphysema were also identified as risk factors in patients undergoing lobectomies, including a history of smoking, COPD, lower FEV1, and a lower diffusing capacity for carbon monoxide. Full-Text PDF