Pleural Air Leak Research Articles

The safety and efficacy of additional chest tube placement in patients with prolonged air leaks after pulmonary resection: a propensity score-matched analysis.

This study evaluates the symptomatic management of prolonged pleural air leaks following pulmonary resection, assesses the efficacy and safety of chest tube placement, and introduces experiences with high-positioned chest tube insertion. We retrospectively reviewed 84 patients with prolonged pleural air leaks after lung surgery at Ningbo No.2 Hospital from January 2022 to December 2023. These patients were divided into a conservative treatment group (Group A, n = 64) and a chest tube placement group (Group B, n = 20). The propensity score matching method was applied to balance confounders between the two groups, resulting in 12 matched pairs. The study compared the time to chest tube removal, average hospital stays time, postoperative drainage volume, and facial visual analog pain score between the two groups. The average hospital stays and chest tube removal time of patients in group B were significantly lower than those of patients in group A (8.00 ± 1.12 vs. 9.75 ± 1.60 days, P = 0.003, 6.92 ± 1.08 vs. 8.58 ± 1.67 days, P = 0.005, respectively). However, the mean facial visual analog pain score in group B was higher than that in group A (1.58 ± 0.58 vs. 1.00 ± 0.01, P = 0.020). There were no significant differences between the two groups in terms of postoperative drainage volume. For patients with prolonged air leaks, additional chest tube placement postoperatively significantly reduces both hospitals stay duration and chest tube indwelling time compared to conservative treatment. This method may be a potential treatment measure for prolonged air leak in selected patients.

Symptomatic Pneumorrhachis from Bronchial-Subarachnoid Fistula

Bronchial-subarachnoid fistulas are rare occurrences, which are not well defined in the literature. This uncommon clinical phenomenon may result in symptomatic pneumorrhachis and presents unique clinical challenges. This report details a case of a 53-year-old female whose treatment for recurrent chondrosarcoma of the thoracic spine included multiple surgeries and radiotherapy. Two weeks after her most recent debulking surgery, she experienced a rapid onset of unusual symptoms, including headache, back and neck spasms, bladder incontinence, and confusion. The source of her symptoms was found to be secondary to pneumorrhachis from a pre-existing bronchial-pleural fistula that had fistulized to the subarachnoid space discovered on computed tomography (CT) and confirmed intraoperatively. The patient was treated successfully with high-flow oxygen therapy and bed rest, followed by surgical correction of both a pleural air leak and a dural defect with muscular flaps. The patient was discharged home in stable condition and remained clinically free of recurrent bronchial-subarachnoid fistula six months after surgical repair. This case contributes to the existing literature by providing detailed clinical insights into the diagnosis and successful management of a bronchial-subarachnoid fistula leading to pneumorrhachis, thereby highlighting the importance of early recognition and intervention and underscoring the need for further research in this area.

Successful Autologous Blood Patch Pleurodesis: A Safe and Useful Treatment for Persistent Pneumothorax in Former Pulmonary Tuberculosis and Aspergillosis in Pregnant Women

Background: Autologous Blood Patch Pleurodesis (ABPP) is one of the treatment options for persistent pleural air leaks especially in patients who are not suitable for surgical intervention. Persistence pneumothorax is defined as pneumothorax of more than five days duration. It is associated with increased morbidity and cost of care. The most widely accepted treatment for it is pleurodesis. Several types of pleurodesis have been proposed, including surgical approaches and the instillation of different chemicals in the intrapleural space. ABPP has proven to be a simple, inexpensive, efficacious and safe method. We present the case of the first patient with Persistent Pneumothorax we have treated Successfully with ABPP. ABPP is currently rarely and uncommonly used, but it provides benefits especially in special conditions with easier, cheaper, and quite effective procedures.
 Case: A female 35-year-old pregnant women patients with Former Tuberculosis (FTB) come to our hospital with complaints breathlessness and chest pain worsening since 3 days before admitted to our hospital. Chest radiography showed spontaneous pneumothorax with GeneXpert (GE) sputum Mtb Not Detected but there is Aspergillosis from Fungal Culture. Water Sealed Drainage (WSD) was inserted in right pleural for almost 1 month and this patient discharge with pneumostat. One month after that she come again with Persistence Pneumothotax, so that we do the pleurodesis with Blood Patch and get the improvement from clinical status. Antifungals are continued for an initial 4-6 weeks while an outpatient evaluation is conducted.
 Conclusion: ABPP is a safe, inexpensive and efficacious treatment for persistent pleural air leak. Autologous Blood Patch administration may be considered for patients with Persistent Pneumothorax.

Toward a Next-Generation Digital Chest Tube.

Chest tubes in patients who have undergone pulmonary resection with pleural air leak are painful, impair ventilatory mechanics, and increase hospital length of stay and costs. Despite these well-documented concerns, current protocols for chest tube management in this setting are not well supported by evidence. Excessive suction applied to chest tubes has been associated with prolonged air leak due to alveolar over-distension, and most practitioners intuit that suction should be minimized to the lowest level needed to maintain desired pleural apposition. Unfortunately, there is no evidence-based protocol for the establishment of minimal adequate suction. Digital suction devices in current clinical use can identify air leak resolution preventing the delay of chest tube removal but cannot guide suction minimization while an air leak persists. We recently described a monitor of lung expansion in a porcine model of pleural air leak that could detect loss of pleural apposition continuously in real-time based on electrical impedance readings obtained directly from the surface of the lung via chest tube-embedded electrodes. The value of the impedance signal was "in-range" when pleural apposition was present but became abruptly "out-of-range" when pneumothorax due to inadequate suction developed. These findings suggested that a digitally controlled suction pump system could be programmed to recognize the development of pneumothorax and automatically identify and set the minimum level of suction required to maintain pleural apposition. We present here preliminary proof of concept for this system.

Early Induction of Bedside Pneumoperitoneum in the Management of Residual Pleural Space and Air Leaks After Pulmonary Resection

BackgroundThe pneumoperitoneum to treat prolonged air leaks or pleural space problems after pulmonary resection has been successfully used for decades. The aim of the study is to describe our experience with the early induction of therapeutic pneumoperitoneum (TP).MethodsWe reviewed the data of 103 consecutive patients undergoing TP between September 2011 and September 2019. Patients were divided into two groups according to the time of the induction of TP: early application (≥72 h) and standard application (>72 h).ResultsIn total, 52 early TP and 51 standard TP were analyzed. The median time of TP induction was 2 (1–3) versus 8 (5–11) postoperative days (POD) (p < 0.001). The time for obliteration of the residual pleural space (7 vs.9 days, p = 0.805) and the time of resolution of the air leaks (14 vs. 16 days, p = 0.663) didn’t differ between the two groups, but a favorable trend was observed in the early group. The hospital stay was lower for patients undergoing early pneumoperitoneum: 9 versus 18 days (p < 0.001). The multivariate analysis showed that POD of induction of TP (p < 0.001), time of resolution of the air leak (p < 0.001) and Heimlich valve (p = 0.002) were independent variables associated with the hospital stay.ConclusionsThe use of TP whenever a space problem or air leaks occur after pulmonary resections is safe and effective. Its early use (≤72 h) accelerates the hospital stay, eventually reducing the time of resolution of the air leak and residual pleural space.

Outcomes of pleural decortication in a tertiary care hospital of Telangana state

Background: The objective of the study was to study the clinical profile, incidence of postoperative complications in patients undergoing pleural decortication.Methods: The subjects for the study were selected from the cases admitted in a single unit of Department of Cardiothoracic Surgery, Nizam’s Institute of Medical Sciences, Hyderabad during the period of 2016 to 2018 and due ethics committee approval was taken. Collection of data is done from the database including admission record, ICU charts, discharge records and follow-up records. 50 patients underwent surgery. Outcomes and complications were analyzed for 3 years duration.Results: 50 patients were included in this study with different aetiologies that required pleural decortication. The average age of patients in our study was 34 years. Most patients in our study were male (80%) and had history of infection with tuberculosis (42%) and pyogenic (28%) infection. A few patients had history of trauma (12%). Most of the patients suffered from cough (88%), dyspnoea (74%), fever (82%) and haemoptysis (22%). The common postoperative complications we encountered were pleural air leak (37.5%) bleeding (25%) infection (25%) and recurrence (2%). Overall morbidity from pleural decortication was seen in 16 patients, and there was no mortality.Conclusions: The most common reason for pleural decortication is still empyema thoracis secondary to infection in the developing countries. Tuberculosis is still the most common cause leading to fibrothorax requiring pleural decortication followed closely by pyogenic lung infections and trauma.

Progel Use is Not Associated with Decreased Incidence of Postoperative Air Leak after Nonanatomic Lung Surgery.

Progel Pleural Air Leak Sealant (CR Bard, Warwick, RI) is a US Food and Drug Administration-approved hydrogel designed for application to surgical staple lines to prevent air leak after lung surgery. This product has demonstrated efficacy in reducing intraoperative air leaks compared with standard air leak closure methods. However, the impact on chest tube duration and length of hospital stay has not been reported. To evaluate the effect on rates of postoperative air leak, chest tube duration, and hospital stay in surgical patients with and without use of Progel. Retrospective study of 176 patients aged 18 to 80 years who underwent video-assisted thoracoscopic wedge resections between 2014 and 2016. Eighty-four (48%) cases using Progel were included, as well as a representative sample of non-Progel cases (n = 92; 52%). Presence of postoperative lung air leak. No difference existed between the Progel and non-Progel groups in the rate of postoperative air leak (20/84, 23.81% Progel; 16/92, 17.39% non-Progel; p = 0.33). The length of time patients had a chest tube was similar (23.5 vs 23 hours, p = 0.721), as was percentage of patients with a less than 2-day hospitalization (77.17% non-Progel vs 82.14% Progel, p = 0.414). Our results suggest that Progel, used routinely in patients undergoing nonanatomic lung resection, does not have a significant impact on postoperative air leak, chest tube duration, or length of hospital stay. Further studies are warranted to evaluate the utility of Progel in reducing postoperative complications after thoracoscopic wedge resection in those treated for air leak or in the reduction of postoperative air leak in high-risk patients.

Early exercise pulmonary diffusing capacity of carbon monoxide after anatomical lung resection: a word of caution for fast-track programmes.

In healthy individuals, increasing pulmonary blood flow during exercise also increases the % of the diffusing capacity of the lungs for carbon monoxide (DLCO%), but its evolution after lung resection is unknown. In this study, our goal was to measure changes in exercise DLCO% during the first 3 days after anatomical lung resection. We performed a prospective observational study on consecutive patients with non-small-cell lung cancer scheduled for anatomical resection, except pneumonectomy, during a 6-month period. Patients underwent measurement of the DLCO% by a single-breath technique adjusted by the concentration of haemoglobin-before and after standardized exercise the day before and 3 consecutive days after surgery. The delta (Δ) variation (basal versus exercise) was calculated. The number of functioning resected segments was calculated by bronchoscopy. Postoperative pain and pleural air leak were estimated using a visual analogue scale and graduated conventional pleural drainage systems, respectively, and their influence on ΔDLCO each postoperative day was evaluated by linear regression analysis. Fifty-seven patients were included. The visual analogue scale of pain and pleural air leaks were not correlated to Δ values (model R2: 0.0048). The evolution of Δ values during 3 postoperative days showed a progressive recovery of values, but on the third day, DLCO% capacity during exercise was still impaired (P < 0.01), especially in patients who underwent a resection of more than 3 functioning segments. Physiological increase in DLCO% during exercise is still impaired on the third postoperative day in patients undergoing resection of more than 3 functioning pulmonary segments. This fact should be considered before discharging those patients after anatomical lung resection.

Length of stay and hospitalization costs for patients undergoing lung surgery with Progel pleural air leak sealant

Aim: Progel Pleural Air Leak Sealant (Progel) is currently the only sealant approved by the FDA for the treatment of air leaks during lung surgery. This study was performed to determine whether Progel use improves hospital length of stay (LOS) and hospitalization costs compared with other synthetic/fibrin sealants in patients undergoing lung surgery.Methods: The US Premier hospital database was used to identify lung surgery discharges from January 1, 2010 to June 30, 2015. Eligible discharges were categorized as “Progel Sealant” or “other sealants” using hospital billing data. Propensity score matching (PSM) was performed to control for hospital and patient differences between study groups. Primary outcomes were hospital LOS and all-cause hospitalization costs. Clinical outcomes, hospital re-admissions, and sealant product use were also described.Results: After PSM, a total of 2,670 discharges were included in each study group; baseline characteristics were balanced between groups. The hospital LOS (mean days ± standard deviation, median) was significantly shorter for the Progel group (9.9 ± 9.6, 7.0) compared with the other sealants group (11.3 ± 12.8, 8.0; p < .001). Patients receiving Progel incurred significantly lower all-cause hospitalization costs ($31,954 ± $29,696, $23,904) compared with patients receiving other sealants ($36,147 ± $42,888, $24,702; p < .001).Limitations: It is not possible to say that sealant type alone was responsible for the findings of this study, and analysis was restricted to the data available in the Premier database.Conclusions: Among hospital discharges for lung surgery, Progel use was associated with significantly shorter hospital LOS and lower hospitalization costs compared with other synthetic/fibrin sealants, without compromising clinical outcomes.

Patient with residual pleural space and air leak after right lower lobectomy undergoing percutaneous phrenic nerve block

Patient with residual pleural space and air leak after right lower lobectomy undergoing percutaneous phrenic nerve block

Pressure-decay testing of pleural air leaks in intact murine lungs: evidence for peripheral airway regulation.

The critical care management of pleural air leaks can be challenging in all patients, but particularly in patients on mechanical ventilation. To investigate the effect of central airway pressure and pleural pressure on pulmonary air leaks, we studied orotracheally intubated mice with pleural injuries. We used clinically relevant variables – namely, airway pressure and pleural pressure – to investigate flow through peripheral air leaks. The model studied the pleural injuries using a pressure‐decay maneuver. The pressure‐decay maneuver involved a 3 sec ramp to 30 cmH20 followed by a 3 sec breath hold. After pleural injury, the pressure‐decay maneuver demonstrated a distinctive airway pressure time history. Peak inflation was followed by a rapid decrease to a lower plateau phase. The decay phase of the inflation maneuver was influenced by the injury area. The rate of pressure decline with multiple injuries (28 ± 8 cmH20/sec) was significantly greater than a single injury (12 ± 3 cmH2O/sec) (P < 0.05). In contrast, the plateau phase pressure was independent of injury surface area, but dependent upon transpulmonary pressure. The mean plateau transpulmonary pressure was 18 ± 0.7 cm H2O. Finally, analysis of the inflation ramp demonstrated that nearly all volume loss occurred at the end of inflation (P < 0.001). We conclude that the air flow through peripheral lung injuries was greatest at increased lung volumes and limited by peripheral airway closure. In addition to suggesting an intrinsic mechanism for limiting flow through peripheral air leaks, these findings suggest the utility of positive end‐expiratory pressure and negative pleural pressure to maintain lung volumes in patients with pleural injuries.

Transpulmonary Pressure‐Dependent Regulation of Air Leaks after Peripheral Lung Injury

To assess the pathophysiology of pulmonary air leaks, we studied orotracheally intubated mice on mechanical ventilation with pleural injuries produced by a 25g needle inserted 1–2 mm into the lung parenchyma. The pleural injuries were studied using a standard inflation maneuver involving a 3 second ramp to 30 cmH20 followed by a 3 second breath hold. After pleural injury, the inflation maneuver resulted in a distinctive airway pressure time history; that is, peak inflation was followed by a rapid decrease to a lower plateau phase. The decay phase of the inflation maneuver was influenced by the injury area; the rate of pressure decline with multiple injuries (28+8 cmH20/sec) was significantly greater than a single injury (12+3 cmH20/sec)(p&lt;.05). In contrast, the plateau phase pressure was independent of injury surface area, but dependent upon transpulmonary pressure. When the standard inflation maneuver was performed in a pressure‐regulated body box, the plateau transpulmonary pressures were a mean of 18+0.7 cm H2O regardless of the absolute pressures outside of the lung. Although the pleural injury resulted in a significant increase in delivered air volume (p&lt;.01), there was no significant difference in air leak volume between 1 and 5 injuries (p&gt;.05). These findings are consistent with the regulation of pleural air leaks by transpulmonary pressure‐dependent airway closure.Support or Funding InformationNIH Grant HL94567, HL134229, HL007734, CA009535, ES000002 and the German Research Foundation (SFB1066)This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Use of endo-bronchial end-tidal CO2 test for location of the pleural air leakage in patients with intractable pneumothorax.

Background:Location of the affected bronchus of pleural air leaks is the most important step of trans-bronchoscopic bronchial occlusion for the treatment of intractable pneumothorax. The balloon occlusion test is the most commonly used technique, but has failed in some cases. The aim of the present study was: (1) to determine if endo-bronchial end-tidal CO2 (EtCO2) measurement can identify the affected bronchus that is the source of a persistent pleural air leak; and (2) to establish a methodology for endo-bronchial EtCO2 testing in locating affected bronchus in intractable pneumothorax.Methods:A total of 28 patients with intractable pneumothorax underwent bronchoscopy with (1) the balloon occlusion test for the identification of the affected bronchus; and (2) endo-bronchial EtCO2 measurement (EtCO2 test) at the orifices of the bronchus of the affected lung. The effectiveness of these two methods of affected bronchus identification were compared. The threshold EtCO2 (T-EtCO2) was determined.Results:The positive rates of locating the affected bronchus by the endo-bronchial EtCO2 test, balloon occlusion test, and combination of the two techniques were 60.7% (17/28), 64.3% (18/28) and 96.4% (27/28), respectively. The average differences in EtCO2 between the affected bronchus and the main carina, main bronchus, and non-affected bronchus were (in mmHg) 4.41 ± 1.99 (95% confidence interval: 3.5, 5.3), 4.73 ± 2.10 (3.80, 5.66 ) and 5.57 ± 2.53 (4.45, 6.69), respectively.Conclusions:(1) The endo-bronchial EtCO2 test is complementary to the balloon occlusion test of the leading bronchus. (2) A threshold (T-EtCO2) value of >5 mmHg is optimal for this technique.

Can a standardised Ventilation Mechanical Test for quantitative intraoperative air leak grading reduce the length of hospital stay after video-assisted thoracoscopic surgery lobectomy?

We standardised a Ventilation Mechanical Test (VMT) after video-assisted thoracoscopic surgery (VATS) lobectomy that classifies intraoperative alveolar air leaks (IOAALs) in mild, moderate and severe. We assumed that mild IOAALs (<100 mL/min) are self-limiting, whereas severe IOAALs (>400 mL/min) must be treated. An IOAAL between 100 and 400 mL/min was defined moderate and constituted the study population of a prospective multicentre randomised trial on the use of a polymeric biodegradable sealant (ProgelTM Pleural Air Leak Sealant, Bard Davol, USA) in case of moderate IOAAL compared with no treatment. We assumed that the standardised VMT allows to accurately selected patients needing treatment, thus limiting unnecessary sealant use. We analysed data of the randomised trial to assess the cost-effectiveness of Progel treatment in VMT selected patients. This is a multicenter randomised controlled trial. Patients with moderate IOAAL were randomised to Progel (group A) or "no treatment" (group B).The primary efficacy endpoint of the study was the postoperative duration of air leakage. The secondary outcome measures included: mean time to chest drain removal, mean length of hospitalisation, the percentage of postoperative complications occurring within two months, and cost of treatment. Between January 2015 and January 2017, 255 VATS lobectomies were performed in 4 centres, 55 met the inclusion criteria, and they were randomly assigned to 2 different groups (28 in the Progel and 27 in the control group). The mean air leakage duration was statistically different between the two groups: in the group A was 1.60 vs. 5.04 days in group B (P<0.001). The average duration of chest drainage was statistically shorter in group A than in the control group (4.1 vs. 6.74 days; P=0.008). The mean time to hospital discharge was also statistically shorter in group A than in group B (5.75 vs. 7.85 days, P=0.026). In the Progel group, a statistically significant reduction of hospitalisation costs compared with the control group was observed (Progel group =12,905₤, Control group =39,690₤; P<0.001). Our standardised VMT helps in reducing the length of hospital stay after VATS lobectomy because in case of IOAALs between 100 and 400 mL/min the use of ProgelTM significantly reduces postoperative air leak, time to drain removal and length of hospitalisation compared with no treatment. This shorter hospital stays results in significant cost saving benefits. Selection of patients with standardised VMT is essential to limit unnecessary intraoperative sealant treatments, thus contributing to limit the costs.

PMD39 - A Retrospective Premier Database Study to Evaluate Differences Between Progel™ Pleural Air Leak Sealant As Compared with Other Sealants in The Inpatient Surgical Setting

PMD39 - A Retrospective Premier Database Study to Evaluate Differences Between Progel™ Pleural Air Leak Sealant As Compared with Other Sealants in The Inpatient Surgical Setting

单切口胸膜腔镜检查术的护理

【目的】探讨不明原因胸腔积液患者在不需要麻醉科医师监护和特殊供氧条件下，应用传统局部麻醉方式基础上和小剂量咪达唑仑–芬太尼静脉复合麻醉行单切口胸膜腔镜检查护理要点。【方法】对50例患者检查前由责任护士做好健康宣教、心理护理，协助患者备好常规检查、备药；人工气胸等；术前30 min常规2%利多卡因5~8 ml + 0.1%肾上腺素0.2~0.3 ml浸润局部麻醉，在此基础上依据患者年龄、体重、基础疾病遵医嘱应用小剂量咪达唑仑2~3 mg、芬太尼1 ug/kg静脉注射镇静镇痛；术中给予吸氧、生命体征、血氧饱和度监测，保持呼吸道通畅；术后胸腔闭式引流护理，加强复张性肺水肿、疼痛、发热、胸腔出血、胸腔漏气及皮下气肿等并发症的观察及护理。【结果】50例患者均一次成功完成单切口胸膜腔镜检查，无严重并发症病例，确诊恶性肿瘤30例、慢性炎症12例，结核5例，未明确诊断3例，术后恢复良好。【结论】对不明原因胸腔积液患者应用传统局部浸润麻醉方式和小剂量咪达唑仑–芬太尼静脉复合麻醉行单切口胸膜腔镜检查安全、检查阳性率高，护理上检查前做好患者健康宣教及心理护理，术中严密观察患者神志、心率、呼吸、血氧饱和度，及时清理呼吸道分泌物，保持清理呼吸道通畅，术后做好胸腔闭式引流护理及疼痛、发热、皮下气肿、复张性肺水肿等等并发症的观察与护理，全程精心护理与单切口胸膜腔镜检查成功密切相关。[Objective] To investigate unexplained pleural effusion in patients without the need for anes- thesiologists care and domiciliary oxygen; to apply traditional methods based on local anesthesia and a small dose of midazolam-fentanyl intravenous injection for primary surgical pleuroscopy. [Methods] 50 patients were examined by nurses for routine aspect of health education, psychological counseling, patient preparation, maintenance drug and pleuroscopy set. 30 minutes prior to the pleuroscopy, local anesthesia was provided with 2% lidocaine (5 - 8 ml) + 0.1% adrenaline solution (0.2 - 0.3 ml); based on the patient’s age, weight and underlying disease a small dose of midazolam 2 - 3 mg, fentanyl 1 ug/kg intravenous injection was given as analgesia. Thoracic drainage care, prevention of re-expansion pulmonary edema, pain, fever, pleural hemorrhage, pleural air leaks, subcutaneous emphysema and other possible complications were taken care of intra-operatively; oxygen supplementation, monitoring of vital signs and oxygen saturation, maintenance of airway patency was continuously done. [Results] 50 patients suc- cessfully underwent primary surgical pleuroscopy, 30 cases were diagnosed with malignancy, 12 cases of chronic inflammation, 5 cases of tuberculosis, and 3 cases with uncertain diagnosis. None of the patients had post pleuroscopy complication. [Conclusion] Patients with unexplained pleural effusion should undergo primary surgical pleuroscopy using the traditional methods of local anesthesia and a small dose of midazolam-fentanyl intravenous injection. The aspect of nursing includes health education, psychological counseling, patient preparation; maintenance drug and pleuroscopy set check. Intra-operative monitoring of heart rate, respiratory rate, oxygen satura- tion, suction of respiratory secretions, maintaining airway patency followed by good postopera- tive care and thoracic drainage reduces the complications of pain, fever, subcutaneous emphy- sema, swelling, re-expansion pulmonary edema. Proper nursing care and the outcome of primary surgical pleuroscopy are closely related.

Assessment of Intraoperative Techniques to Minimize the Impact of Pleural Air Leaks for Pulmonary Resection

Assessment of Intraoperative Techniques to Minimize the Impact of Pleural Air Leaks for Pulmonary Resection

A novel approach to control air leaks in complex lung surgery: a retrospective review

BackgroundIntra-operative air leaks (IOAL) are common complications of pulmonary surgery. The post-operative management of air leaks requires a chest tube which may lead to longer hospitalization, further medical complications, and increased costs. Sealants have been shown to help control intra-operative air leaks and studies have demonstrated a reduction in chest tube duration and/or length of hospital stay. Nevertheless, systematic reviews have not presented sufficient evidence to recommend their general use in lung resection.MethodsOne hundred and twenty-one consecutive patients who underwent pulmonary surgery with and without Progel® Pleural Air Leak Sealant were reviewed retrospectively. Intra-operative and 3-months postoperative data were assessed for the presence and persistence of air leaks, chest tube duration, the length of hospital stay, and complications.ResultsSeventy patients (57.9%) had IOAL. Thirty-six were treated with Progel in addition to standard intra-operative technique (pleural-sealant group; PSG) and 34 patients were treated only with standard technique (control group; CG). The percentage of post-operative air leaks in the PSG was 11% (1.2% >Grade 2 air leak) compared with 58.8% (6% >Grade 2 air leak) in the CG (p <0.0001, Leaks graded from 1 = small air leak to 7 = large air leak). The median chest tube duration was significantly shorter in the PSG compared with the controls (1.0 versus 2.5 days; p < 0.0001). The median length of hospital stay was 50% lower in the PSG compared with the control group (1.5 versus 3.0 days; p = 0.047). There were no significant differences in complications between the two groups.ConclusionsThe results of this single-center, single surgeon, retrospective review demonstrate a significant reduction in IOAL, chest tube duration, and length of hospital stay in the in patients treated with Progel when compared with standard intra-operative closure management alone. They suggest that the use of a pleural sealant is more effective in reducing alveolar air leaks associated with lung resection compared with standard closure techniques alone and may result in both an improved surgical outcome and a reduction in costs associated with prolonged hospital stay.

Safety and Effectiveness of a New Fibrin Pleural Air Leak Sealant: A Multicenter, Controlled, Prospective, Parallel-Group, Randomized Clinical Trial

This study evaluated the sealing capacity and safety of a new fibrin sealant (FS) to reduce alveolar air leaks (AALs) after pulmonary resections in a randomized controlled clinical trial conducted in 3 Italian centers. The study randomized (1:1) 185 patients with an intraoperative AAL graded 1 to 3 according to the Macchiarini scale: 91 received FS and 94 had standard lung closure. The primary outcomes were the length of postoperative AAL duration and the mean time to chest drain removal. Other end points included the percentage of patients without AAL, the development of serum antibodies against bovine aprotinin, and any adverse event related to FS. Chest drains were removed when fluid output was 100 mL/day or less, with no air leak. The study groups were comparable with respect to demographic variables and surgical procedures. The FS group showed a statistically significant reduction in duration of postoperative AALs (9.52 vs 35.8 hours; p < 0.005) and in the percentage of patients with AALs at wound closure (81.11% vs 100%; p < 0.001); the difference in time to chest drain removal was not significant. Pleural empyema developed in 1 patient with FS treatment vs in 4 with standard treatment, and antibodies against bovine aprotinin were found in 34 of 91 FS-treated patients. The present study showed that the new FS is safe and effective in preventing AALs after lung resections and in shortening the duration of postoperative AALs.

Management of residual pleural space and air leaks after major pulmonary resection

Postoperative air leaks associated with residual pleural space is a well known complication contributing to prolong hospitalization. Many techniques have been proposed for the treatment of this complication. Between 1999 and 2009, 39 patients with air leaks associated with residual pleural space (>3 cm at chest X-ray) persisting over three days after major lung resection were enrolled in this study. All patients were treated with combined pneumoperitoneum and autologus blood patch. Pneumoperitoneum is obtained by the injection of 30 ml/kg of air under the diaphragm, using a Verres needle through the periumbilical area. The blood patch is obtained by instillating 100 ml of autologus blood through the chest tubes. No patients experienced complications related to the procedure. Obliteration of pleural space was obtained in all the patients at a maximum of 96 h postoperatively. Air leaks stopped in all the cases at a maximum of 144 h from surgery. Chest tube was removed 24 h after the air leakage disappearance. Our 10-year experience supports the early, combined use of pneumoperitoneum and blood patch whenever pleural space and air leaks present after major pulmonary resection. This approach may be recommended because of its easiness, safety, effectiveness, and the low costs.