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.
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.
|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
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)
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)
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).
|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.
|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
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