Postsurgical pleurodesis with autologous blood in patients with persistent air leak

BACKGROUND: Persistent air leak after operation on the lung is one of the most common problems encountered by thoracic surgeons. We present 6 patients who underwent pleurodesis with autologous blood for persistent air leak after operation. METHODS: Between June 1993 and January 1998, pleurodesis with autologous blood was performed in 6 patients who had air leak of more than 10 days' duration after operation for non-small cell lung cancer. A sample of peripheral blood was taken from the patient's arm and immediately introduced into the chest tube with no additives. The chest tube was left unclamped and off suction, connected to the waterseal drainage, and kept 60 cm above the patient's chest. The next day, the waterseal and chest roentgenogram were reviewed before the chest tube was removed. RESULTS: A persistent air leak with a mean duration of 16.7 days was observed after the initial operation. Fifty to 250 mL of blood was introduced one time into the chest tube. No patient experienced pain, respiratory difficulty, fever, or episodes of coughing during the procedure. After 24 hours, no air leak was detected in the waterseal drainage in any patient. CONCLUSIONS: On the basis of these preliminary findings, we believe pleurodesis with autologous blood is a safe and effective method for treating persistent air leak after a thoracic surgical procedure.     

Autologus platelet gel for the management of persistent alveolar fistula after lung resection

Postoperative alveolar fistula (AF) associated with pleural cavity (PC) is a serious complication and a therapeutic challenge in thoracic surgery. The purpose of this study was to assess the efficacy of the use of the autologous platelet gel for the treatment of AF and PC. We treated a patient with post lung resection persistent alveolar fistula using a autologous platelet gel, a cellular compose produces at the Division of Immunohaematoligy and Trasfusion. The platelet gel-PRP (Platelet-Rich Plasma) is a biological material made of autologous platelets, extracted from a small amount of the patient's blood, centrifuged at 1100 g for 9 min. The PRP obtained was activated by addition of autologous thrombin and calcium chloride to form a matrix of fibrin (PRFM) thick. The patient presented important air leak after middle lobe wedge resection for solitary lung lesion with standard open decortication for important pleural adhesions post pleuritis. On postoperative day XIII the patient developed a thoracic empyema and consequently underwent a antibiotic pleural irrigation through the chest drainage based on the microbiological analysis of the pleural fluid. After a week we obtained the resolution of the empyema but a residual space remained and air leak persisted. We treated the patient with autologous platelet gel. We administer 7.5 mL of the autologous platelet gel across the chest drainage ever 72 hours for 3 times. After the third application we had the closure of the cavity and the cessation of air leak. Autologous platelet gel is easy to use, safe and inexpensive. It can be considered a valid therapeutic option in selected patients with a alveolar fistula and a lung partial re-expansion. The product consist of a significant amount of cellular components with healing anti-inflammatory an proregenerative properities that permit the body to heal tissue wounds faster and more efficiently. A sterile pleural cavity is fundamental conditions for the final success of the procedure.     

Persistent air-leak following pulmonary resection

Air leaks are an unavoidable complication of pulmonary resection. The definition of a persistent air leak is arbitrary and may even be irrelevant in solving the problem. Persistent air leaks are more common in patients with severe COPD, and preoperative interventions are ineffective in reducing their prevalence. Meticulous surgical technique and care in handling and resection of the pulmonary parenchyma are essential in preventing persistent air leaks. Buttressing parenchymal staple lines and creating a pleural tent or pneumoperitoneum should be reserved for patients at risk for persistent air leaks. The use of currently available sealants is ineffective for the treatment of this complication. To stop persistent air leaks, early cessation of suction and placing chest tubes to an underwater seal is more effective than continuous suction. The management of persistent air leaks may require provocative chest tube clamping and permissive chest tube removal or patient discharge from the hospital with a chest tube and a Heimlich valve.     

Autologous blood pleurodesis for treatment of prolonged air leak in secondary spontaneous pneumothorax

Background  

Persistent air leak after secondary spontaneous pneumothorax is one of the most common problems encountered by thoracic surgeons. The aim of this study was to assess the value of autologous blood pleurodesis to seal prolonged air leaks.     

Early use of autologous blood patch pleurodesis in children is successful in resolving persistent air leaks

PurposeExperience with autologous blood patch (ABP) pleurodesis for persistent air leak in the pediatric population is limited. The purpose of this series was to describe the experience with ABP at a single tertiary children's hospital.MethodsA retrospective study was performed of all thoracic procedures done by the pediatric surgery service over three years.ResultsTen patients underwent a total of 17 ABPs. The median age of patients was 12 years (IQR 6–16). The most common underlying reasons for a thoracic procedure included: blebectomy for spontaneous pneumothorax (2), need for lung biopsy (2), resection of known malignant tumor (2), and empyema (2). The median number of days of persistent air leak before first ABP was 7.5 days (IQR 7–10). A second ABP was performed in 6 cases with a third procedure performed in one case. None of the patients developed respiratory compromise during ABP and no infectious complications were identified following ABP.ConclusionsOur cohort demonstrates that ABP for persistent air leak following thoracic surgery is effective with minimal morbidity in children. We believe ABP can be used early and in patients with a broad range of underlying lung pathology.     

Prospective randomized trial compares suction versus water seal for air leaks

BACKGROUND: Surgeons treat air leaks differently. Our goal was to evaluate whether it is better to place chest tubes on suction or water seal for stopping air leaks after pulmonary surgery. A second goal was to evaluate a new classification system for air leaks that we developed. METHODS: Patients were prospectively randomized before surgery to receive suction or water seal to their chest tubes on postoperative day (POD) #2. Air leaks were described and quantified daily by a classification system and a leak meter. The air-leak meter scored leaks from 1 (least) to 7 (greatest). The group randomized to water seal stayed on water seal unless a pneumothorax developed. RESULTS: On POD #2, 33 of 140 patients had an air leak. Eighteen patients had been preoperatively randomized to water seal and 15 to suction. Air leaks resolved in 12 (67%) of the water seal patients by the morning of POD #3. All 6 patients whose air leak did not stop had a leak that was 4/7 or greater (p < 0.0001) on the leak meter. Of the 15 patients randomized to suction, only 1 patient's air leak (7%) resolved by the morning of POD #3. The randomization aspect of the trial was ended and statistical analysis showed water seal was superior (p = 0.001). The remaining 14 patients were then placed to water seal and by the morning of POD #4, 13 patients' leaks had stopped. Of the 32 total patients placed to seal, 7 (22%) developed a pneumothorax and 6 of these 7 patients had leaks that were 4/7 or greater (p = 0.001). CONCLUSIONS: Placing chest tubes on water seal seems superior to wall suction for stopping air leaks after pulmonary resection. However, water seal does not stop expiratory leaks that are 4/7 or greater. Pneumothorax may occur when chest tubes are placed on seal with leaks this large.     

Autologous blood patch for persistent air leak in children

Purpose

Persistent air leak (PAL) is associated with increased morbidity. Standard treatment of PAL includes chemical or mechanical pleurodesis. Long-term impact of these interventions is not known in the pediatric population. Autologous blood patch (ABP) offers a novel treatment option. We report our experience with autologous blood patch to successfully treat PAL in eight children.

Methods

Children with PAL were treated with ABP. A fresh whole blood sample was obtained from each patient and injected via their pre-existing chest tube. Volume of blood injected, time to cessation of air leak, time to chest tube removal, outcomes and complications were reviewed.

Results

Eight children aged 2 months to 18 years underwent ABP. Three children had immediate seal of air leak, while two patients sealed after 1 and 2 days. Three patients required a second ABP, after which they had immediate seal of air leak. Chest tubes were removed within 2–3 days in 7 cases. One child developed an asymptomatic pneumothorax and required 8 days for radiographic resolution.

Conclusion

ABP appears to be a safe and effective treatment option for PAL in children. ABP offers an inexpensive, easy to perform technique and avoids use of toxic chemicals for pleurodesis in pediatric patients.     

Pneumoperitoneum for the management of pleural air space problems associated with major pulmonary resections.

BACKGROUND: The use of pneumoperitoneum to treat prolonged air leaks or space problems, or both, after pulmonary resection has been recently resurrected and used successfully. METHODS: During the last 3 years, 14 patients experienced short-term pleural space problems associated with prolonged air leaks after pulmonary resection for lung cancer. All patients, under sedation and local anesthesia, had a mean of 2,100 mL of air injected under the diaphragm, using a Veres needle after a mean time of 7 days (range, 5 to 10 days) from the operation. In 3 patients talc slurry was added to help control the air leak. RESULTS: No patients experienced complications during the induction of the pneumoperitoneum. No patients complained of dyspnea, although blood gas analysis showed a slight increment of carbon dioxide partial pressure (p < 0.0004). Obliteration of the pleural space was observed in all cases after a mean time of 4 days (range, 1 to 7 days). Air leaks stopped in all patients after a mean time of 8 days (range, 4 to 12 days). The mean postoperative hospital stay after lung resection was 18 days (range, 14 to 22 days). No patients had significant complications or long-term sequelae. We found that patients who had undergone induction chemotherapy had longer air leak durations than observed in noninduction patients (p = 0.03). CONCLUSIONS: Our experience supports the use of postoperative pneumoperitoneum whenever a space problem associated with prolonged air leaks is present. The procedure is effective, safe, and easy to perform.     

Life-threatening complications related to minocycline pleurodesis

For decades, chemical pleurodesis using minocycline has been widely accepted as an effective, safe, and cheap treatment for persistent air leak after pulmonary resection. We report a case with persistent postoperative air leak that suffered from cardiorespiratory arrest just after a minocycline pleurodesis, which may be related to the aspiration of minocycline solution from a bronchopleural fistula. Therefore, we suggest a bronchoscopic examination be performed before the pleurodesis if a bronchopleural fistula is highly suspected.     

Management of air leak after pulmonary resection

Objective: We prospectively evaluated the efficacy of water seal in the management of air leak after pulmonary resection. Methods: Eighty-seven patients who underwent lobectomy were enrolled. Air leak was qualitatively described on each postoperative day using a six-grade scale. All chest tubes were continuously suctioned at a negative pressure of 12 cm H₂O until the morning of postoperative day (POD) 1. Switch was made to water seal if the air leak was graded as “minor at expiration” or lower. This procedure is referred to as “the water seal challenge”. Results: On POD 1, 58 patients had air leaks. The water seal challenge was attempted on POD 1.6±1.0. While 45 patients (78%) continued to receive the water seal, the remaining 13 patients were switched to suctioning at −5 cm H₂O followed by the successful second water seal challenge within 3 days from the first challenge. The air leak stopped 3.1±3.0 days after the application of the water seal in the 58 patients. None of the following correlated with the duration of air leak: preoperative pulmonary function tests, type of lobectomy, age, and gender. Only the leak grade on POD 0 correlated significantly with the duration of air leaks (p<0.0001). Conclusion: These results show that water seal is a safe and effective management option for air leak during the early postoperative period.     

A different application method of talc pleurodesis for the treatment of persistent air leak

Persistent air leak is a serious problem that may cause empyema, hypoxia, respiratory insufficiency, and other life-threatening complications. Chemical pleurodesis may be carried out for the treatment of persistent air leak if the lung is fully expanded. However, the standard method of chemical pleurodesis entails clamping the chest tube for a period of time after instillation of the agent. In patients with massive air leak, this would result in a tension pneumothorax. Therefore, standard chemical pleurodesis for persistent air leak is not an appropriate treatment for these patients. In this study, we carried out talc pleurodesis in six patients using an inverted U-shaped chest tube elevated to 60 cm that did not result in tension pneumothorax and mediastinal shift. No recurrence was observed during a mean follow up of 16.2 months.     

负压吸引与常规引流对肺切除术后迁延性肺瘘的作用分析

目的研究分析持续负压吸引和常规闭式引流对肺切除术后迁延性肺瘘（PAL）中所起的作用和价值。方法将我院2004年3月至2011年5月203例肺切除术患者随机分为负压组（98例）和常规组（105例）。负压组于术后第一天胸腔引流管连接负压吸引装置,给予持续低负压吸引（压力为-10至-20cmH：O）。常规组手术后仅行常规的胸腔闭式引流。对两组并发症、PAL发生率以及漏气时间进行统计分析。结果本组共行肺切除术203例,发生迁延性肺瘘24例,发生率11．8％。负压组98例,出现并发症48例,其中迁延性肺瘘14例（14．3％）;常规组105例,出现并发症33例,其中迁延性肺瘘10例（9．5％）。负压组平均漏气时间5．3d,常规组4．9d,两组间差异无统计学意义（P〉0．05）;两组均无死亡病例。结论肺切除术后持续负压吸引并没有降低漏气持续时间以及PAL的发生率,在防治PAL的过程中持续负压吸引并不优于常规的闭式引流,不推荐肺切除术后常规使用负压吸引。     

Initial chest tube management after pulmonary resection

Tube thoracostomy management with suction or water seal after anatomical pulmonary resection remains somewhat controversial. Initial chest tube management may influence the duration of pleural fluid drainage, duration of tube thoracostomy, and/or hospital length of stay following pulmonary resection. We hypothesized that initial chest tube management with water seal decreases time for chest tube removal and decreases time of hospital stay. A retrospective chart review was performed on 109 consecutive patients who underwent lobectomy or segmentectomy in Western Pennsylvania Hospital between December 1999 and December 2003. Comparison was made between chest tube management of water seal or suction in patients with and without air leak. Of the 109 patients, 78 (72%) had no air leak at the completion of surgery, and 31 (28%) had air leak. In the group without air leak (n = 78), water seal was used in 32 (41%) patients and suction in 46 (59%). In patients placed to water seal initially after surgery (n = 32), removal of chest tubes was on postoperative day (POD) 3.19 +/- 0.24 and hospital discharge was on POD 5.13 +/- 0.61. In patients placed to suction initially (n = 46), chest tubes were removed on POD 4.52 +/- 0.40. Hospital discharge was on POD 6.74 +/- 0.5. Both duration of chest tube (P < 0.007) and length of hospital stay (P < 0.04) were significantly lower in the water seal group. In the air leak group (n = 31), 7 (23%) patients were managed with water seal and 24 (77%) patients with suction. Both duration of chest tube (P = 0.001) and length of hospital stay (P < 0.05) were significantly lower in the water seal group. In patients without air leak, chest tubes should be managed with water seal following anatomical pulmonary resection, resulting in significantly shorter chest tube duration and hospital length of stay.     

Endobronchial valve treatment of persistent alveolopleural fistulae in a patient with cystic fibrosis and empyema

Persistent air leak (PAL) is a common problem after secondary pneumothorax due to cystic fibrosis (CF). These leaks, caused by either bronchopleural or alveolopleural fistula, are associated with higher morbidity and mortality [1]. Air leaks are traditionally treated with chronic chest tube drainage, chemical pleurodesis, or autologous blood patching in non-surgical candidates [1]. However, these strategies can increase infectious risk or pleural scarring, which are associated with poorer lung transplant surgical outcomes. Endobronchial valve (EBV) placement, while FDA-approved for use in both some surgical PALs and bronchoscopic volume reduction therapy, is one alternative option, but it could theoretically increase the risk of infection, especially in CF patients. Here, we report the case of a CF patient under evaluation for lung transplant who received EBVs for PAL after bilateral secondary spontaneous pneumothoraces.     

Effect of intravenous administration of coagulation factor XIII concentrate on persistent pleural air leak

We administered coagulation factor XIII concentrate intravenously to six patients suffering from persistent air leak with no evidence of bronchopleural fistulae They are those who had either failed to be healed in response to pleurodesis, intrapleural fibrin glue injection and surgery or had not received such treatment. Their blood coagulation factor XIII activity levels were less than 70% of the standard plasma level. In four of the six patients, air leak stopped within 10 days after the treatment begun. Because factor XIII plays an important role in wound healing, reduction in the activity level can be a cause of insufficient healing of pulmonary surface fistulae and may lead to persistent air leak. In such cases, intravenous administration of factor XIII concentrate increases the activity levels and may put an end to persistent air leak.     

Extrapleural bullectomy or lung volume reduction: air tight surgery for emphysema without strip-patch.

Air leaks after stapled lung resections for emphysema remain the most common postoperative complication. Staple line reinforcement, alone or in association with a parietal pleural tent, is recognised as an effective technique for decreasing the occurrence of air leaks after pulmonary wedge resection. Several materials have been employed for reinforcement, most of them prosthetic and costly. We use the parietal pleural tent covering the pulmonary targets to be excised, as a reinforcement on which the staple is fired (2 LVRS and 6 bullectomy procedures). Air tightness and obliteration of intrapleural space are simultaneously achieved. We named our technique: Extrapleural Bullectomy (EB) or Extrapleural Lung Volume Reduction (ELVR), according to the indication of the operation. No mortality nor significative morbidity, particularly prolonged postoperative air leak, were observed. At the follow-up (3 to 12 months) no pneumothorax or residual spaces have occurred.     

Comparison of water seal and suction after pulmonary lobectomy: a prospective, randomized trial

BACKGROUND: The objective of the present study was to assess whether placing chest tubes on water seal after pulmonary lobectomy reduced the duration of air leak compared with suction. METHODS: One hundred forty-five patients who underwent pulmonary lobectomy for lung cancer and with an air leak on the first postoperative day were prospectively randomly assigned to two groups: in group 1 (72 patients), chest tubes were placed on water seal on the morning of the first postoperative day; in group 2 (73 patients), chest tubes were on continuous suction (-20 cm H(2)O). Eighty percent of the patients who underwent upper lobectomy had also a pleural tent procedure. Preoperative, operative, and postoperative variables were compared between the groups. RESULTS: The two groups were evenly matched for preoperative and operative characteristics. No statistically significant differences were found between group 1 and group 2 in terms of air leak duration (6.5 versus 6.3, respectively; p = 0.9) and the incidence of prolonged air leak cases (27.8% versus 30.1%, respectively; p = 0.8). Similar results were obtained when the analysis was corrected for the length of the stapled parenchyma and the site of resection (upper and lower resections) or restricted to patients with a forced expiratory volume in 1 second less than 80% of predicted. Water seal patients had increased postoperative complications compared with suction patients (31.9% versus 17.8%, respectively; p = 0.056). CONCLUSIONS: Chest tubes placed on water seal after pulmonary lobectomy were generally well tolerated and safe; however, they did not reduce the duration of air leak or the incidence of prolonged air leak compared with suction.     

Reduction of persistent air leak with endoscopic valve implants

The standard management of air leaks due to persistent bronchopleural fistula involves chest drainage and occasionally pleurodesis, with intractable cases requiring surgical decortication or surgical repair. However, some of these patients may be at high risk for surgery, particularly if they have already had thoracic surgery or have other medical problems; for this group there is a need for less invasive methods of stopping or reducing air leaks. Emphasys endobronchial valves (EBV) are occlusive devices designed primarily for endoscopic lung volume reduction in emphysema. Because the device is a one-way inspiratory airway blocker, it is possible that it could be used in controlling persistent air leaks while maintaining the drainage of secretions. Two cases are reported of persistent air leaks that were managed by endoscopic occlusion with EBV. In one case complete stoppage of the air leak was achieved with immediate clinical benefits. The second patient died 5 days after treatment from additional complications apparently not related to the procedure. Endobronchial blockage may be a useful salvage procedure for patients with persistent air leak for whom there is no other treatment available.     

Comparative transoral dural closure techniques: a canine model

A watertight dural closure is difficult to achieve after transoral-transclival operation for ventral intradural lesions at the craniocervical junction. These procedures have a high morbidity and mortality from cerebrospinal fluid (CSF) fistula, meningitis, and abscess. We used a canine model to test three different techniques of dural closure after transoral intradural operation: primary suture closure, laser patch weld, and fibrin glue patch closures. The primary suture closure technique was inadequate. All eight leaked CSF at the time of operation, and five had radiographic leaks and were incompetent at autopsy. All seven of the laser closures leaked CSF at operation, yet only one was incompetent at autopsy. The fibrin glue technique was superior and provided a solid seal at operation, even with repeated Valsalva maneuvers to 40 mm Hg. The immediate and persistent seal at operation is clinically significant because it may prevent CSF leak, meningitis, and abscess formation in human patients after transoral surgery. Fibrin glue is excellent for repairing complex dural defects and merits evaluation in clinical trials.     

Predictors of prolonged air leak after pulmonary lobectomy

BACKGROUND: The objective of this study was to identify the predictors of prolonged air leak (air leak longer than 7 days) in patients submitted to pulmonary lobectomy for lung cancer. METHODS: A retrospective analysis on 588 patients operated on of pulmonary lobectomy from January 1995 through June 2003 was performed. Univariate and logistic regression analyses were performed to generate a model predicting the risk of prolonged air leak. Bootstrap resampling technique was used to validate the regression model. RESULTS: A prolonged leak was exhibited by 15.6% of patients. Logistic regression analysis demonstrated that significant independent predictors of prolonged air leak were a reduced predicted postoperative forced expiratory volume in 1 second (p < 0.0001), the presence of pleural adhesions (p = 0.003), and upper resections (p = 0.006). Bootstrap resampling analysis confirmed the reliability of these variables. A regression equation was generated for the prediction of the risk of prolonged air leak. CONCLUSIONS: We report that a low predicted postoperative forced expiratory volume in 1 second, the presence of pleural adhesions, and the upper lobectomy or bilobectomy increased the risk of air leak persisting for more than 7 days. A model was generated to calculate this risk and assist the surgeon in taking extra measures to prevent such complication (ie, optimizing bronchodilator treatment, pleural tent, sealants, buttressed staple lines, water seal, and chest tube drainage).