Prolonged Airleak After Lobectomy

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Prolonged Airleak After Lobectomy

Authors: Laura Donahoe, Anne-Sophie Laliberté and Simon Turner

SUMMARY OF RECOMMENDATIONS

  • Patient factors, type of lung resection and intra-operative findings may predict which patients are at high risk for prolonged air leak (PAL).
  • Prevention of PAL should be considered with intraoperative techniques (fissureless dissection and careful tissue handling) especially in high-risk patients.
  • Minimizing external suction on chest tubes is recommended to reduce PAL.
  • Patients with PAL can be safely managed as an outpatient with a portable drainage device.
  • Chemical pleurodesis or blood patch may be effective at treating PAL.

INTRODUCTION

Prolonged post-operative air-leak is one of the most common complications after thoracic surgery, with an incidence ranging from 2% to 58% in the literature(1-3).  In addition to prolonging hospital stay, prolonged air leaks (PALs) are associated with higher rates of post-operative pain, empyema, pneumonia, venous thromboembolism, need for additional procedures and overall cost(4, 5).  Many studies have tried to determine which patients are at higher risk for developing PALs, which intra-operative techniques might help to prevent PALS, and how to best manage PALs when they happen.

Our recommendations are based on literature review and are in line with the consensus of the CATS Positive Deviance Seminar on this subject.

RISK FACTORS

Risk factors
Patients factors (4,6) ·         Low forced expiratory volume in one second (FEV1)

·         Low diffusion capacity for carbon monoxide (DLCO)

·         Low body mass index (<25)

·         Male sex
Surgical factors (1,3,4,7,8) ·         Lower lobes

·         Anatomic lung resection (e.g. lobectomy and bilobectomy)

·         Length of the staple line

·         Pleural adhesions

·         Degree of intra-operative air leak
Post-operative factors (7) ·         Mechanical ventilation

·         Subcutaneous emphysema

·         Massive air leak on post-op day 1

·         Incomplete lung expansion

SCORING SYSTEM

In order to be able to perform an individual patient risk assessment, a number of scores have been developed to determine risk of PAL.

Scoring system to predict the risk of PAL
Lee et al. (McGill) (6): based on the presence of pleural adhesions and pre-op FEV1 and DLCO
Seder et al. (2): groups patients into high and low risk of PAL
Pompili et al. (9): using the European Society of Thoracic Surgeons database, grouped patients into 4 risk classes based on:

–          male gender (1 point)

–          FEV1<80% (1 point)

–          BMI<18.5kg/m2.

The risk of PAL was 6% in class A (0 points), 10% in class B (1 point), 13% in class C (2 points) and 25% in class D (>2 points)

 

PREVENTION

A standardized approach to prolonged air leak reduction after lobectomy has shown a reduction of 40-52% of air leaks and a reduction of 3 days of hospital stay in The Society of Thoracic Surgeons National Database analysis (11).

Prevention Strategies
Fissureless technique (12,13)

·         Decreases the incidence of PAL, time to air leak cessation and duration of chest tube placement.
Careful tissue handling (10,12)

·         Laceration must be repaired

In high-risk patients consider:

·         Use of sealants

·         Staple line buttressing
No suction (10,14-17)

·         Regardless of the drainage system used (digital or standard) no initial suction should be favoured (-8cm H20 or less on a digital device).

·         Suction should be strictly reserved for incomplete lung expansion and should not be used to treat PAL.

MANAGEMENT

Management Strategies
Outpatient management (19)

·         Consider discharging patients with PAL with chest tubes connected to one-way valves or digital drainage devices

·         Complications are rare, though some series report a significant risk of empyema

·         Consider social factors and patient’s ability to manage the tube at home
Chemical pleurodesis and blood patch (18,19)

·         Small series suggest efficacy of a variety of chemical agents including talc, bleomycin, tetracycline, minocycline, OK 432 and glucose solutions

·         Complete lung expansion may be necessary for effective results.

·         Avoid talc if there is risk of active infection or a possibility of further surgery in the future

·          Autologous blood injected into the pleural space may also be effective, though a significant rate of empyema has been reported.
Endobronchial valves (18,19)

·         The use of endobronchial valves for PAL is poorly studied and their use cannot be recommended for or against at this time

REFERENCES

  1. Okereke I, Murthy SC, Alster JM, Blackstone EH, Rice TW. Characterization and importance of air leak after lobectomy. Ann Thorac Surg. 2005;79(4):1167-73.
  2. Seder CW, Basu S, Ramsay T, Rocco G, Blackmon S, Liptay MJ, et al. A Prolonged Air Leak Score for Lung Cancer Resection: An Analysis of The Society of Thoracic Surgeons General Thoracic Surgery Database. Ann Thorac Surg. 2019;108(5):1478-83.
  3. Casha AR, Bertolaccini L, Camilleri L, Manche A, Gauci M, Melikyan G, et al. Pathophysiological mechanism of post-lobectomy air leaks. J Thorac Dis. 2018;10(6):3689-700.
  4. Clark JM, Cooke DT, Brown LM. Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula. Thorac Surg Clin. 2020;30(3):347-58.
  5. Petrella F, Spaggiari L. Prolonged air leak after pulmonary lobectomy. J Thorac Dis. 2019;11(Suppl 15):S1976-S8.
  6. Lee L, Hanley SC, Robineau C, Sirois C, Mulder DS, Ferri LE. Estimating the risk of prolonged air leak after pulmonary resection using a simple scoring system. J Am Coll Surg. 2011;212(6):1027-32.
  7. Pischik VG, Maslak OS, Obornev AD, Zinchenko EI, Kovalenko AI. Risk factors and outcomes of prolonged air leak after pulmonary resections. Indian J Thorac Cardiovasc Surg. 2019;35(4):564-8.
  8. Brunelli A, Salati M, Pompili C, Gentili P, Sabbatini A. Intraoperative air leak measured after lobectomy is associated with postoperative duration of air leak. Eur J Cardiothorac Surg. 2017;52(5):963-8.
  9. Pompili C, Falcoz PE, Salati M, Szanto Z, Brunelli A. A risk score to predict the incidence of prolonged air leak after video-assisted thoracoscopic lobectomy: An analysis from the European Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg. 2017;153(4):957-65.
  10. Geraci TC, Chang SH, Shah SK, Kent A, Cerfolio RJ. Postoperative Air Leaks After Lung Surgery: Predictors, Intraoperative Techniques, and Postoperative Management. Thorac Surg Clin. 2021;31(2):161-9.
  11. Drahush N, Miller AD, Smith JS, Royer AM, Spiva M, Headrick JR, Jr. Standardized Approach to Prolonged Air Leak Reduction After Pulmonary Resection. Ann Thorac Surg. 2016;101(6):2097-101.
  12. Deguchi H, Tomoyasu M, Shigeeda W, Kaneko Y, Kanno H, Saito H. Reduction of air leakage using linear staple device with bioabsorbable polyglycolic acid felt for pulmonary lobectomy. Gen Thorac Cardiovasc Surg. 2020;68(3):266-72.
  13. Murakami K, Hamaji M, Morita S, Ueno K, Nakajima D, Ohsumi A, et al. Prolonged air leak after reoperative pulmonary resection (with prior ipsilateral chest surgery). Interact Cardiovasc Thorac Surg. 2020;31(4):544-6.
  14. Holbek BL, Christensen M, Hansen HJ, Kehlet H, Petersen RH. The effects of low suction on digital drainage devices after lobectomy using video-assisted thoracoscopic surgery: a randomized controlled trialdagger. Eur J Cardiothorac Surg. 2019;55(4):673-81.
  15. Mitsui S, Tauchi S, Uchida T, Ohnishi H, Shimokawa T, Tobe S. Low suction on digital drainage devices promptly improves post-operative air leaks following lung resection operations: a retrospective study. J Cardiothorac Surg. 2021;16(1):105.
  16. Baringer K, Talbert S. Chest drainage systems and management of air leaks after a pulmonary resection. J Thorac Dis. 2017;9(12):5399-403.
  17. Mayor JM, Lazarus DR, Casal RF, Omer S, Preventza O, Simpson K, et al. Air Leak Management Program With Digital Drainage Reduces Length of Stay After Lobectomy. Ann Thorac Surg. 2018;106(6):1647-53.
  18. French DG, Plourde M, Henteleff H, Mujoomdar A, Bethune D. Optimal management of postoperative parenchymal air leaks. J Thorac Dis. 2018;10:S3789-98.
  19. Geraci TC, Chang SH, Shah SK, Kent A, Cerfolio RJ. Postoperative air leaks after lung surgery: Predictors, intraoperative techniques, and postoperative management. Thorac Surg Clin. 2021;31:161-9.