Management Of Persistent Air Leak Research Articles

Thoracoscopic blood patch instillation for persistent air leak in pneumothorax: a case series and systematic review.

Persistent air leaks in patients with pneumothorax can lead to significant morbidity. If a patient with persistent air leak is medically unfit for thoracic surgery, medical pleurodesis via chest tube or thoracoscopy is either an option. Thoracoscopy offers the advantage of visualizing the site of the air leak and enabling direct instillation of the pleurodesis agent or glue at that location. Autologous blood patch instillation via chest tube has been reported to be a cheap and very effective technique for the management of persistent air leaks. However, thoracoscopic blood patch instillation has not been reported in the literature. We report two cases of secondary spontaneous pneumothorax in which patients had persistent air leaks for more than seven days and were subjected to thoracoscopy to locate the site of the leak. In the same sitting, 50 mL of autologous blood patch was instilled directly at the leak site. Post-procedure, the air leak subsided in both patients, and the chest tube was removed with complete lung expansion. We also conducted a systematic review of the use of medical thoracoscopic interventions for treating persistent air leaks.

Managing Spontaneous Pneumothorax and Treating Severe Community-Acquired Pneumonia

THE FIRST European guidelines for the management of primary spontaneous pneumothorax (PSP) were presented in a symposium session delivered at the European Respiratory Society (ERS) International Congress 2023 on the 9th–13th of September in Milan, Italy. The novel guidelines covered new recommended approaches to acute pneumothorax, optimal management of persistent air leak (PAL), and analysed the evidence for the changing use of co-adjuvants in severe community-acquired pneumonia (SCAP).

Endobronchial Valves for Management of Persistent Air Leaks in Patients With Chronic Lung Disease

BackgroundPersistent air leak (PAL) is a challenging problem in patients with spontaneous pneumothorax and chronic lung disease who are poor surgical candidates. Conventional management consists of long-term thoracostomy tube placement; however, in some cases, patients are unable to leave the hospital because of the need for continuous negative pressure. We investigated the application of endobronchial valves (EBVs) in the management of patients with air leak for whom surgical intervention was contraindicated. MethodsEBVs were placed in patients with PALs arising from nonoperative causes. Successful outcomes were defined as the ability to remove the thoracostomy tube from suction, resolution of air leak, and removal of chest tube. ResultsSeventeen patients with PAL requiring negative pressure suction were treated with EBVs. The overall complete successful outcome rate was 82.4%. There was a statistically significant reduction in length of stay after valve placement in the success group compared with the failure group (8.9 days vs 61.7 days; P = .0097). ConclusionsEBVs are a valid option for patients who are not surgical candidates and have failed to respond to conventional management of PAL. This experimental use of EBVs leads to high success rates and shorter length of stay when it is successful.

Management of persistent air leak in Neonates: A case series

Background: Autologous blood patch pleurodesis (ABPP) has been used in adults as an efficient and safe technique to address persistent air leak (PAL). A fibrin glue patch is also an alternative, but its elevated cost and technique can limit its routine use. Evidence of their use in the pediatric population, specifically in the neonatal age is scant. Case Presentation: We share our management experience in a series of 3 cases. The first 2 were treated exclusively with ABPP and showed clinical and radiographic improvement. The 3rd case, due to the persistence of the air leak, required extended thoracotomy and fibrin patch placement. Conclusion: The use of ABPP as an alternative for the treatment of neonates with PAL is a safe and efficient technique. The procedure is replicable and can be done at the bedside at a low cost. A fibrin glue patch should be considered as an alternative option when ABPP fails to resolve the leak.

The Efficacy and Safety of Autologous Blood Patch for Persistent Air Leaks: A Systematic Review and Meta-Analysis.

Persistent air leaks (PALs) are associated with prolonged hospital stays, contaminationand sustained infection of the pleural space, and significant morbidity. A fistulous tract between the alveoli and the pleural space is referred to as analveolar-pleural fistula (APF), whereas a fistulous tract between the bronchiole and the pleural space is referred to as a bronchopleural fistula (BPF). There is no consensus on the treatment, and multiple modalities exist for the management of persistent air leak (PAL). Autologous blood patch (ABP) is a relatively safe and inexpensive method that has been used for many years for the treatment of PALs. We conducted an electronic database search between 08/24/2022 and 08/27/2022 in PubMed, Embase, and Cochrane using keywords. The following keywords were used: "Blood patch" OR "Autologous blood patch" AND "pleurodesis."Our study included all original studies with the prime focus on the etiology of PALs, clinical characteristics, procedural details of ABP, and outcomes of the proposed treatment. The primary outcomes that were the focus of our study were the time to seal the air leak, the time to remove the chest tube after air leak cessation, and the time to discharge from the hospital. To determine the safety of ABP, we also evaluated the procedural outcomes. Our findings suggest a statistically significant decrease in the time to air leak cessation when compared to the control group (mean difference of -3.75 {95% CI: -5.65 to -1.85; P=0.001}) with considerable heterogeneity of I2=85% and P=0.001. However, the difference was not statistically significant when a lower dose of ABP (50 mL) was compared to a higher dose (100 mL) (mean difference of 1.48 {95% CI: -0.07 to 3.02; P=0.06}) and considerable heterogeneity of I2=80% and P=0.03. There was no statistically significant difference in the time to discharge when compared to the control group (mean difference of -2.12 {95% CI: -4.83 to 0.59; P=0.13}) and considerable heterogeneity (I2=95% and P<0.001). When compared to the control group, ABP did not provide any statistically significant difference in the risk ratio for infection (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I2=33% and P=0.20}), pain (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I2=33% and P=0.20}), and fever (0.54 {95% CI: 0.27 to 1.10; P=0.09} and no heterogeneity {I2=0% and P=0.50}). Our study concludes that using ABP caused a statistically significant decrease in the time to air leak cessation when compared to the control group. However, the procedure does not provide a statistically significant difference in the time to discharge from the hospital when compared to conservative treatment. Similarly, there was no statistically significant difference in the risk ratio for complications such as infection, pain, and fever when compared to conservative management. More studies need to be conducted to fully understand the efficacy and safety of ABP in the management of PALs.

Autologous blood patch pleurodesis for persistent air leak in the setting of chronic non-invasive ventilation: case report

Background: Persistent air leaks (PAL) are associated with significant morbidity and mortality, including prolonged length of hospital stays, increased re-admission rates and increased incidences of pneumonia and pleural space infections. Autologous blood patch pleurodesis (ABPP) may be used in the management of PAL, however it is unclear whether this treatment option can be used in patients requiring chronic non-invasive ventilation.

Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation.

COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU/hospital discharge.

ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

ENDOBRONCHIAL VALVES FOR TREATMENT OF PERSISTENT AIR LEAK AFTER SECONDARY SPONTANEOUS PNEUMOTHORAX IN PATIENTS WITH CYSTIC FIBROSIS

Comparison of efficacy of autologous blood patch pleurodesis versus doxycycline pleurodesis in the management of persistent air leak in patients with secondary spontaneous pneumothorax. A randomized control trial.

Secondary spontaneous pneumothorax (SSP) patients sometimes have a persistent air leak (PAL) that leads to increased morbidity and increased hospital stay. Further, these patients also need pleurodesis to prevent a recurrence. Autologous blood patch pleurodesis (ABPP) has been successfully tried in post lobectomy air leak cases. However, its utility in SSP patients with PAL has not been widely established. In this context, we performed a non-blinded randomized control study to compare the efficacy of ABPP vs doxycycline pleurodesis in the closure of air leak in SSP patients. This study was a non-blinded randomized control study done in 38 SSP patients with PAL. They were randomized into doxycycline arm and ABPP arm. Post pleurodesis air leak was assessed every 12 hours for cessation. Success was considered when there was a complete cessation of air leak. Post-procedural complications were noted and patients were followed up for 28 days to look for recurrence. The median time for closure was 24 hours [interquartile range (12.24)] for ABPP and 36 hours [interquartile range (24.72)] for doxycycline pleurodesis. Success rate of ABPP vs doxycycline pleurodesis is 94.7% vs 84.2% (p=0.6). Post-procedure pain was more in doxycycline group (15% vs 73%) (p<0.01). On visual analogue scale, ABPP had a lesser pain as compared to doxycycline pleurodesis (average visual analogue scale value of 2 vs scale of 7). The recurrence rate was equal in both groups (5%). Though ABPP and doxycycline have similar success rates, ABPP has an early closure of air leak and greater patient tolerability. ABPP can be tried as an alternative to doxycycline pleurodesis in SSP patients with persistent air leaks.

Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience.

Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes. In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction. Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients. PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

Use of Valved Dry Seal Chest Drain in Ambulatory Management of Persistent Air Leak

Use of Valved Dry Seal Chest Drain in Ambulatory Management of Persistent Air Leak

Evaluation and endoscopic management of persistent air leaks

The endoscopic management of persistent or prolonged air leak (PAL) has gained popularity, not only in post-surgical PAL but also in non-surgical scenarios. The literature that supports an endoscopic approach is restricted to case series, case reports, retrospective and some small prospective studies. Every patient who suffers from PAL secondary to bronchopleural fistula (BPF) or alveolopleural fistula (APF) should always be evaluated to determine surgical repair candidacy. There have been a number of articles that summarize the bronchoscopic modalities for the management of PAL, but none emphasize the initial evaluation with an algorithmic approach or discuss how to follow-up these patients in the immediate post- treatment phase and long-term. Medical causes of PAL are, in our opinion, more difficult to localize and consequently treat compared to surgical causes of air leak. The bronchoscopic management for either surgical or non-surgical BPF’s is similar. In this review, we discuss the initial evaluation, management and follow up with an algorithmic approach of PAL as well as review the available endoscopic modalities.

Management of Persistent Air Leaks Using Endobronchial Autologous Blood Patch and Spigot Occlusion: A Multicentre Randomized Controlled Trial in China

Background: Optimal management of persistent air leaks (PALs) in patients with secondary spontaneous pneumothorax (SSP) remains controversial. Objective: To evaluate the efficacy and safety of endobronchial autologous blood plus thrombin patch (ABP) and bronchial occlusion using silicone spigots (BOS) in patients with SSP accompanied by alveolar-pleural fistula (APF) and PALs. Methods: This prospective multicentre randomized controlled trial compared chest tube-attached water-seal drainage (CTD), ABP, and BOS that were performed between February 2015 and June 2017 in one of six tertiary care hospitals in China. Patients diagnosed with APF experiencing PALs (despite 7 days of CTD) and inoperable patients were included. Outcome measures included success rate of pneumothorax resolution at the end of the observation period (further 14 days), duration of air leak stop, lung expansion, hospital stay, and complications. Results: In total, 150 subjects were analysed in three groups (CTD, ABP, BOS) of 50 each. At 14 days, 60, 82, and 84% of CTD, ABP, and BOS subjects, respectively, experienced full resolution of pneumothorax (p = 0.008). All duration outcome measures were significantly better in the ABP and BOS groups than in the CTD group (p < 0.016 for all). The incidence of adverse events, including chest pain, cough, and fever, was not significantly different. All subjects in the ABP and BOS groups experienced temporary haemoptysis. Spigot displacement occurred in 8% of BOS subjects. Conclusion: ABP and BOS resulted in clinically meaningful outcomes, including higher success rate, duration of air leak stop, lung expansion, and hospital stay, with an acceptable safety profile.

Management of Persistent Air Leaks with Intrabronchial Valves.

Persistent air leaks (PALs) are regarded as a frequent complication after thoracic surgery resulting in prolonged hospitalization and increased morbidity. Several more or less invasive therapeutic approaches are available for treatment of PAL with varying degrees of success. The endoscopic placement of one-way intrabronchial valves in the segment(s) in which the air leak has been located offers a highly effective and well-tolerated minimal invasive option for patients with PAL.

Endobronchial Valve for Secondary Pneumothorax in a Severe Emphysema Patient

Secondary pneumothorax represents a challenging problem in patients with chronic obstructive pulmonary disease, due to their compromised health status. In this case, an endobronchial one-way valve was inserted in the left lower lobe by flexible bronchoscopy, resulting in a complete resolution of air leak and lung reexpansion. Endobronchial valve could represent a new option for the management of persistent air leak in patients not suitable for surgical procedures.

Intrapleural instillation of autologous blood for persistent air leak in spontaneous pneumothorax- is it as effective as it is safe?

ObjectiveThe aim of the present study was to evaluate the efficacy of autologous blood pleurodesis in the management of persistent air leak in spontaneous pneumothorax.Patients and methodsA number of 15 patients (10 male and 5 female) were included in this prospective study between March 2005 and December 2009. The duration of the air leak exceeded 7 days in all patients. The application of blood pleurodesis was used as the last preoperative conservative method of treatment in 12 patients. One patient refused surgery and two were ineligible for operation due to their comorbidities. A blood sample of 50 ml was obtained from the patient's femoral vein and immediately introduced into the chest tube.ResultsA success rate of 27% was observed having the air leak sealed in 4 patients in less than 24 hours.ConclusionDespite our disappointingly poor outcome, the authors believe that the procedure's safety, convenience and low cost establish it as a worth trying method of conservative treatment for patients with the aforementioned pathology for whom no other alternative than surgery would be a choice.

Pleurodesis using autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome

Objective Pneumothorax is present as a frequent complication in acute respiratory distress syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax. Design The study was a case-control, prospective, nonrandomized one comparing 2 groups subjected to artificial pairing (1:1). Setting The study took place at the Torrecardenas Hospital (Andalusian Health Service, Almería, Spain). Patients Participants were 2 groups of 27 patients, all with ARDS, pneumothorax, and PAL. Interventions One group received conventional treatment whereas the other received PAB. Main results The severity of the conditions of both groups is homogeneous, shown by sex; age; Murray, Marshall, and Acute Physiology and Chronic Health Evaluation II scores; and etiology of ARDS. The patients in the PAB group had a shorter stay in the ICU, shorter weaning time (WT), and lower death rate. The average differences between the groups were 11 days less WT (adjusted odds ratio [OR] = 0.1) and 9 days less on average time spent in the ICU (adjusted OR = 0.24). The death rates in the PAB group and the control group were 3.7% and 29.6%, respectively (adjusted OR = 0.6). Conclusions The use of PAB makes possible a decrease in ventilator WT and a shorter stay in the ICU, with a resulting increase in functional recuperation and decrease in patient mortality.

Treatment of primary spontaneous pneumothorax in Switzerland: results of a survey

Few trials to guide clinical management of primary spontaneous pneumothorax (PSP) exist. This study aims to reveal current practice in the management of PSP in Switzerland, to define the level of consensus and to provide evidence in guiding clinical practice. Questionnaires were sent to 355 departments of internal medicine and surgery in Switzerland and 114 (32.1%) were available for analysis. Recommendations based on the highest consensus are extracted. Good to very good consensus is reached in 63% of all management options. There is very good consensus for the management of clinically stable or unstable patients with small or large PSP, for the treatment of patients without chest tubes and the operative management of persistent air leaks and recurrence prevention. There is good consensus concerning the role of suction, the size of chest tubes, and the use of CT-scans. However, there is little consensus concerning chest tube removal and chemical pleurodesis. Good and very good consensus exists for most management options in the treatment of PSP in Switzerland. The given recommendations can be used as evidence in guiding clinical practice in circumstances where no evidence of higher levels exists.

Les fuites aériennes prolongées (FAP) : attitude conservatrice ou interventionnelle ?

An air leak following pulmonary resection is generally defined as persistent, or prolonged, if it fails to resolve within the first post-operative week. The precise definition has varied from study to study. Persistent air leak represents the most frequent complication in patients undergoing general thoracic procedures. The groups most at risk are elderly patients, patients with chronic obstructive pulmonary disease (COPD), and those who have general risk factors such as diabetes mellitus or who are taking oral steroids. The surgical procedures most commonly affected are upper lobectomies and lung volume reduction surgery for end-stage emphysema. Technically, performing a pleural tent at the time of an upper lobectomy may decrease the incidence of prolonged air leak. Reinforcement or buttressing of the staple line has been shown to decrease both the incidence and the duration of air leaks, but this increases costs and should thus be reserved for patients with lung parenchyma at the highest risk. The use of biological glues can be helpful in reducing the duration of chest tube drainage when applied intraoperatively for moderate and/or severe parenchymal air leaks, however, their systematic use in not recommended. The management of chest tube drainage after pulmonary resection varies widely from one institution to another. Most recent reports have favoured early discontinuation of negative pressure drainage and a move to underwater seal drainage (from the second post-operative day), however, no large scale randomised study is yet available to compare this with a more conservative approach. The management of persistent air leak following surgery requires identification of risk factors, good surgical technique and appropriate chest tube management.

Pleurodesis by autologous blood: a new concept in the management of persistent air leak in acute respiratory distress syndrome

Objective: Pneumothorax is present as a frequent complication in acute respiratory distress syndrome (ARDS). Persistent air leak (PAL) prolongs pneumothorax in 2% of cases of ARDS, increasing the rate of mortality by 26%. Pleurodesis using autologous blood (PAB) is an effective method in cases of oncological pulmonary surgery. The goal of this study was to compare PAB with the conventional drain and water seal in the management of PAL in patients with ARDS and pneumothorax. Design: The study was a case-control, prospective, nonrandomized one comparing 2 groups subjected to artificial pairing (1:1).