Persistent Air Leak Research Articles

OA19 A complex case of bilateral pneumothoraces due to probable certolizumab driven rheumatoid lung nodules

OA19 A complex case of bilateral pneumothoraces due to probable certolizumab driven rheumatoid lung nodules

Review of patients discharged post thoracic surgery with chest drain in situ and nurse-based follow-up clinic.

Persistent air leaks and prolonged drainage are recognized complications of thoracic surgery, increasing hospital stay and costs. Patients can be discharged with a chest drain and followed up in a nurse-led clinic. We reviewed such patients and the rate of readmission after discharge to assess the effectiveness of the drain follow-up clinic. We conducted a retrospective review of our prospective database spanning 22 months, from March 2019 to January 2021. The analysis focused on the indication and duration of chest drainage, complications, and readmission for any reason. 62 patients (representing 5% of all thoracic surgery patients) were discharged with a chest drain. The median age was 67 years (range 22-85 years), with 24 females and 38 males. 52% underwent video-assisted thoracoscopic surgery, 27% had a thoracotomy, and 21% had bedside chest drain insertion. Following discharge, the median duration of chest drainage was 11 days [interquartile range (IQR) 7-18.75 days]. Patients had 106 review episodes in the ward-based nurse-led clinic. The indications were prolonged air leak (71%; 72 clinic reviews), persistent fluid drainage following empyema evacuation (16%; 24 clinic reviews), and persistent fluid drainage for simple effusion (13%; 10 clinic reviews). The median length of drain stay was 30 days (IQR 19.75-54 days) for empyema, 10 days (IQR 6-16 days) for air leak, and 8 days (IQR 6.5-12 days) for simple effusion. 9 patients required readmission (14.5%), and empyema had developed in 3 patients (4.8%). Patients discharged with a chest drain in place can be followed up in a dedicated ward-based nurse-led monitoring clinic for optimal quality of care.

Preoperative CT-Guided Coil Localization of Lung Nodule Resection: A Single-Center Experience.

The increased use of computed tomography (CT) for lung cancer screening has led to an increase in the incidence of lung nodules. However, accurately localizing small or deep-seated nodules remains challenging and often requires image-guided techniques. CT-guided coil localization has emerged as a popular method for precise localization. A retrospective analysis was conducted on a cohort of patients who underwent CT-guided coil localization followed by surgical resection of lung nodules at the National University Hospital, Singapore, between 2015 and 2021. The study examined the rates of successful localization, procedural complications, and postoperative length of stay. Descriptive statistics were employed for data analysis. This retrospective study included 55 patients with pulmonary nodules, of whom 76.4% had a history of previous malignancy. A total of 58 nodules were successfully localized using coil placement and distributed across various lung lobes. The average dimensions of the nodules were 8.4 ± 3.2 mm × 10.1 ± 4.0 mm, with an average distance of 10.9 ± 9.0 mm from the pleura. Surgical resection of the coiled nodules resulted in an average resected volume of 91.1 ± 76.0 cm3 and a resection margin of 9.5 ± 7.3 mm. Failed localization occurred in only 3.6% of cases. Procedural complications were observed in 21.8% of patients, including hemothorax, persistent air leaks, pneumothoraces, pleural effusion, pneumonia, and atelectasis, all of which were appropriately managed. The average length of postoperative hospital stay was 6.7 ± 15.9 days. Preoperative CT-guided coil localization is a reliable and safe technique for accurately localizing lung nodules before surgical resection. The high success rate of this approach enables precise intraoperative planning. Despite procedural complications, their manageable nature and the absence of major adverse events highlight the safety of this technique. Incorporating CT-guided coil localization into routine clinical practice can significantly enhance surgical planning, improve patient outcomes, and optimize resource utilization.

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.

A rare cause of air-leak syndrome in a premature newborn: a case report

BackgroundPulmonary complications, such as airway leak syndrome, are common in preterm neonates; however, bronchial rupture is a rarely seen phenomenon.Case PresentationIn this case, we present a preterm newborn who developed pneumomediastinum and pneumothorax. The pneumothorax persisted, despite placement of a thorax tube, requiring a thoracotomy to detect and treat the bronchial rupture.ConclusionPhysicians should have a high suspicion of bronchial rupture in patients with persistent air leak syndrome, even after thorax tube placement and continuous negative pressure implementation.

Feasibility of a Novel Diagnostic Technique for Persistent Air Leak by Endobronchial CO 2 Insufflation.

Feasibility of a Novel Diagnostic Technique for Persistent Air Leak by Endobronchial CO 2 Insufflation.

Thoracoscopic segmentectomy in children with congenital lung malformation

Congenital lung malformations (CLM) are most commonly treated with a pulmonary lobectomy. However, due to technological advancement, video-assisted thoracoscopic surgery (VATS) segmentectomy is becoming an attractive alternative to VATS lobectomy. This study aimed to evaluate the safety, feasibility, and efficacy of VATS segmentectomy as a lung parenchyma-saving strategy in children with CLM. A retrospective analysis was performed on 85 children, for whom VATS segmentectomy was tried for CLM between January 2010 and July 2020. We compared the surgical outcomes of VATS segmentectomy with the outcomes of 465 patients who underwent VATS lobectomy. Eighty-four patients received VATS segmentectomy and thoracotomy conversion was necessary for one patient for CLM. The mean age was 3.2 ± 2.5 (range 1.2–11.6) years. The mean operative time was 91.4 ± 35.6 (range 40–200) minutes. The median duration of chest tube drainage was 1 (range 1–21) day, and the median length of postoperative hospital stay was 4 (range 3–23) days. There were no postoperative mortality and postoperative complications developed in 7 patients (8.2%), including persistent air leakage in 6 patients (7.1%) and postoperative pneumonia in 1 patient (1.2%). The median follow-up period was 33.5 (interquartile range 31–57) months and there were no patients requiring re-intervention or reoperation during the follow-up period. In the VATS segmentectomy group, the persistent air leakage rate was higher than in the VATS lobectomy group (7.1 vs. 1.1%, p = 0.003). Otherwise, postoperative outcomes were comparable between the two groups. VATS segmentectomy in children with CLM is a technically feasible alternative to VATS lobectomy with acceptable early and mid-term outcomes. However, the persistent air-leakage rate was higher in VATS segmentectomy.

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.

Pediatric Custom Tracheostomies: A Ten-Year Experience.

To describe the use of customized and custom tracheostomies at our institution, and to identify trends in patient presentation and tracheostomy design. A retrospective review was conducted for patients at our institution for whom a customized or custom tracheostomy tube was ordered between January 2011 and July 2021. Customized tracheostomy tubes allow for a small selection of alterations to trach design, such as cuff length and flange type. Custom tracheostomies have a unique design created by tracheostomy tube engineers in collaboration with the clinical provider, and are built specifically for a single patient. A total of 235 patients were included, of whom 220 (93%) received customized tracheostomies and 15 custom (7%). The most common indications for customized tracheostomy were tracheal or stomal breakdown on a standard tracheostomy (n = 73, 33%) and ventilation difficulties (n = 61, 27%). The most frequent customization was shaft length (n = 126, 57%). The most common indication for custom tracheostomies was a persistent air leak on a standard or customized trach (n = 9) and the most frequent designs were custom cuffs (n = 8), flanges (n = 4), and anteriorly curved shafts (n = 4). Patients treated with a customized tracheostomy had a 5-year overall survival of 75.3%, compared to 51.4% for custom. These are the first cohorts of pediatric patients with customized and custom tracheostomies to be described. Modifications to tracheostomies, in particular shaft length and cuff design, can address common complications of extended tracheostomy, and may help improve ventilation in the most challenging cases. 4 Laryngoscope, 134:452-458, 2024.

Management of Persistent Pulmonary Air Leak with the Drentech™ Simple System. Case Report

Persistent pulmonary air leak affects between 10-15% of pulmonary surgical procedures, generally requiring management through the use of conventional chest drainage systems (water-sealed pleural chamber) of subjective interpretation due to poor detection sensitivity. of leaks, resulting in increased morbidity, hospital stay, and costs.

Simulation in thoracic surgery-A mini review of a vital educational tool to maximize peri-operative care and minimize complications.

Thoracic surgery is an increasingly expanding field, and the addition of national screening programs has resulted in increasing operative numbers and complexity. Thoracic surgery overall has an approximately 2% mortality and 20% morbidity with common specific complications including persistent air leak, pneumothorax, and fistulas. The nature of the surgery results in complications being unique to thoracic surgery and often very junior members of the surgical team feel underprepared to deal with these complications after very little exposure during their medical school and general surgical rotations. Throughout medicine, simulation is being increasingly used as a method to teach the management of complicated, rare, or significant risk occurrences and has shown significant benefits in learner confidence and outcomes. In this mini review we explain the learning theory and benefits of simulation learning. We also discuss the current state of simulation in thoracic surgery and its potential future in aiding complication management and patient safety.

Portrayal of video-assisted mediastinoscopic lymphadenectomy’s range subsequent to its simultaneous use with uniportal VAT-lobectomy for left-sided NSCLC: a case-based perspective

BackgroundVideo-assisted mediastinoscopic lymphadenectomy (VAMLA) is the most precise approach combining staging and therapeutic interventions in non-small cell lung cancer (NSCLC). In the case of left-sided NSCLC, the likelihood of mediastinal lymph node metastases depends on the involvement of the left lung regional lymphatic network. As such, it appears obvious – at least for selected patients with mediastinal staging by either PET-CT or EBUS-TBNA ± EUS-FNA and with cN ≤ 2 – to merge VAMLA and left-sided video-assisted thoracoscopic (VAT) lobectomy for a single-stage therapeutical procedure.Case presentationWe present the clinical course of an 83-year-old patient following simultaneous VAMLA and VAT-lobectomy for invasive mucinous adenocarcinoma of the left upper lobe with a provisional cT3cN0cM0 stage. The patient developed a clinically relevant postoperative pneumothorax due to a persistent parenchymal air leak. CT scan revealed a substantial pneumomediastinum and showed the capability of VAMLAs range for mediastinal lymph node dissection in a unique way. Following the prompt insertion of a second chest tube, the situation was stabilized with an unremarkable further in-hospital stay. The patient remains free of tumor recurrence or distant metastases at a one-year follow-up.ConclusionPresenting this aperçu, we encourage reviving the debate on (1) precise mediastinal staging in general and (2) VAMLA’s important role as a diagnostic and therapeutic tool.

A prospective study of position selection combined with autologous blood intrathoracic infusion in the treatment of postoperative persistent air leakage with an unexpanded lung

We prospectively studied 17 patients with spontaneous pneumothorax or giant emphysematous bulla at Rizhao Hospital of Traditional Chinese Medicine from October 2020 to March 2022. All patients underwent thoracoscopic interventional therapy, had experienced continued air leakage for 3 days with closed thoracic drainage postoperatively, had an unexpanded lung on CT, and/or failed to intervention with position selection combined with intra-pleural thrombin injection(referred to as "position plus1.0"). They were all treated with position selection combined with autologous blood (100 ml) and thrombin (5 000 U) intra-pleural injection(referred to as "position plus 2.0").The success rate of the "position plus 2.0" intervention was 16/17, and the recurrence rate was 3/17. There were four cases of fever, four cases of pleural effusion, one case of empyema, and no other adverse reactions. This study has shown that the "position plus 2.0" intervention is safe, effective, and simple for patient with persistent air leakage failed to intervention with"position plus 1.0" after thoracoscopic treatment of pulmonary and pleural diseases related to bulla.

Fissureless technique of robotic left lingular segmentectomy for primary lung cancer with incomplete fissure: a case report

BackgroundPulmonary segmentectomy for a lung with an incomplete interlobar fissure may complicate persistent air leakage. The fissureless technique is often used in lobectomy to prevent persistent air leakage. We herein describe successful use of the fissureless technique for segmentectomy with the aid of a robotic surgical system.Case presentationA 63-year-old man was clinically diagnosed with early-stage lung cancer for which lingular segmentectomy was indicated. A preoperative image revealed a lung with an incomplete fissure. Based on three-dimensional reconstruction imaging, we planned to divide the hilum structures in the order of the pulmonary vein, bronchus, and pulmonary artery and finally resect the lung parenchyma by dividing the intersegmental plane and interlobar fissure. This fissureless technique was successfully conducted using a robotic surgical system. The patient did not develop persistent air leakage and was alive without recurrence 1 year after segmentectomy.ConclusionsThe fissureless technique may be a useful option in segmentectomy for a lung with an incomplete interlobar fissure.

Hypoxemia After Endobronchial Valve Deployment for Persistent Air Leak

Endobronchial valves (EBVs) are a novel, minimally invasive bronchoscopic management technique for persistent air leaks that fail conservative therapy. Currently, 2 EBVs are available in the United States: the Spiration Valve System (Olympus, Redmond, WA) and the Zephyr Valve (Pulmonx, Redwood, CA). These valves are Food and Drug Administration-approved to reduce hyperinflation in emphysematous patients via bronchoscopic lung-volume reduction. However, more recently, the Spiration Valve has been granted a compassionate use exemption through the Food and Drug Administration for persistent postsurgical air leaks. Despite their popularity, these devices are not free from side effects. As an anesthesiologist, it is vital to be aware of the pathophysiology of this patient population so that safe and effective anesthetics may be provided during valve placement. Here, the use of EBVs is discussed in a patient who presented with a persistent air leak after a transthoracic needle aspiration that failed treatment due to persistent hypoxemia, warranting EBV removal.

Management of primary spontaneous pneumothorax in children: Current practices among Turkish pediatric surgeons.

This study aims to evaluate current practices in the management of primary spontaneous pneumothorax among Turkish pediatric surgeons. Between October 2021 and November 2021, an online survey comprising 19 questions was delivered to all members of the Turkish Association of Pediatric Surgeons (TAPS). A total of 74 respondents (42 males, 32 females; mean age: 42.3±7.9 years; range, 29 to 61 years) were included. The response rate was 17.1% among all society members. The rate of utilization of computed tomography in the initial admission was 27.4%, and the rate of use in cases requiring surgical treatment was 78.4%. A total of 81% of surgeons reported that the size of the pneumothorax influenced management. For the first episode of primary spontaneous pneumothorax, 75.7% of surgeons opted for chest tube drainage, 14.9% for only oxygen administration, 4.1% for needle aspiration, and none of the surgeons preferred video-assisted thoracoscopic surgery. For patients with a persistent air leak after chest tube placement, there was a wide variation in the duration of observation before performing surgery. Video-assisted thoracoscopic surgery was the most preferred surgical intervention (75.3%) and the most preferred surgical method was stapled bullectomy (43.8%). There are practice variations in the management of pediatric primary spontaneous pneumothorax among the society members. However, the majority of members seem to agree on the use of computed tomography, initial treatment, and surgical interventions.

Bioadhesive patch as a parenchymal sparing treatment of acute traumatic pulmonary air leaks.

Traumatic pulmonary injuries are common in chest trauma. Persistent air leaks occur in up to 46% of patients depending on injury severity. Prolonged leaks are associated with increased morbidity and cost. Prior work from our first-generation pectin patches successfully sealed pulmonary leaks in a cadaveric swine model. We now test the next-generation pectin patch against wedge resection in the management of air leaks in anesthetized swine. A continuous air leak of 10% to 20% percent was created to the anterior surface of the lung in intubated and sedated swine. Animals were treated with a two-ply pectin patch or stapled wedge resection (SW). Tidal volumes (TVs) were recorded preinjury and postinjury. Following repair, TVs were recorded, a chest tube was placed, and animals were observed for presence air leak at closure and for an additional 90 minutes while on positive pressure ventilation. Mann-Whitney U test and Fisher's exact test used to compare continuous and categorical data between groups. Thirty-one animals underwent either SW (15) or pectin patch repair (PPR, 16). Baseline characteristics were similar between animals excepting baseline TV (SW, 10.3 mL/kg vs. PPR, 10.9 mL/kg; p = 0.03). There was no difference between groups for severity of injury based on percent of TV loss (SW, 15% vs. PPR, 14%; p = 0.5). There was no difference in TV between groups following repair (SW, 10.2 mL/kg vs. PPR, 10.2 mL/kg; p = 1) or at the end of observation (SW, 9.8 mL/kg vs. PPR, 10.2 mL/kg; p = 0.4). One-chamber intermittent air leaks were observed in three of the PPR animals, versus one in the SW group ( p = 0.6). Pectin patches effectively sealed the lung following injury and were noninferior when compared with wedge resection for the management of acute traumatic air leaks. Pectin patches may offer a parenchymal sparing option for managing such injuries, although studies evaluating biodurability are needed.

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.

Risk of persistent air leaks following percutaneous cryoablation and microwave ablation of peripheral lung tumors.

To compare the incidence of persistent air leak (PAL) following cryoablation vs MWA of lung tumors when the ablation zone includes the pleura. This bi-institutional retrospective cohort study evaluated consecutive peripheral lung tumors treated with cryoablation or MWA from 2006 to 2021. PAL was defined as an air leak for more than 24h after chest tube placement or an enlarging postprocedural pneumothorax requiring chest tube placement. The pleural area included by the ablation zone was quantified on CT using semi-automated segmentation. PAL incidence was compared between ablation modalities and a parsimonious multivariable model was developed to assess the odds of PAL using generalized estimating equations and purposeful selection of predefined covariates. Time-to-local tumor progression (LTP) was compared between ablation modalities using Fine-Gray models, with death as a competing risk. In total, 260 tumors (mean diameter, 13.1mm ± 7.4; mean distance to pleura, 3.6mm ± 5.2) in 116 patients (mean age, 61.1years ± 15.3; 60 women) and 173 sessions (112 cryoablations, 61 MWA) were included. PAL occurred after 25/173 (15%) sessions. The incidence was significantly lower following cryoablation compared to MWA (10 [9%] vs 15 [25%]; p = .006). The odds of PAL adjusted for the number of treated tumors per session were 67% lower following cryoablation (odds ratio = 0.33 [95% CI, 0.14-0.82]; p = .02) vs MWA. There was no significant difference in time-to-LTP between ablation modalities (p = .36). Cryoablation of peripheral lung tumors bears a lower risk of PAL compared to MWA when the ablation zone includes the pleura, without adversely affecting time-to-LTP. • The incidence of persistent air leaks after percutaneous ablation of peripheral lung tumors was lower following cryoablation compared to microwave ablation (9% vs 25%; p = .006). • The mean chest tube dwell time was 54% shorter following cryoablation compared to MWA (p = .04). • Local tumor progression did not differ between lung tumors treated with percutaneous cryoablation compared to microwave ablation (p = .36).

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.