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Ann Thorac Surg 1998;66:1726-1731
© 1998 The Society of Thoracic Surgeons

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Original articles: general thoracic

A prospective algorithm for the management of air leaks after pulmonary resection

^a Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama, USA

Address reprint requests to Dr Cerfolio, Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294-0006

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Air leaks (ALs) are a common complication after pulmonary resection, yet there is no consensus on their management.

Methods. An algorithm for the management of chest tubes (CT) and ALs was applied prospectively to 101 consecutive patients who underwent elective pulmonary resection. Air leaks were graded daily as forced expiratory only, expiratory only, inspiratory only, or continuous. All CTs were kept on 20 cm of suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H₂O of suction. If a pneumothorax was present without an AL, the CT was returned to 20 cm H₂O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry.

Results. There were 101 patients (67 men); on postoperative day 1, 26 had ALs and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV₁/FVC) (p = 0.005), increased age (p = 0.007), increased ratio of residual volume to total lung capacity (RV/TLC) (p = 0.04), increased RV (p = 0.02), and an increased functional residual capacity (FRC) (p = 0.02) to predict the presence of an AL on postoperative day 1. By postoperative day 2, 22 patients had expiratory ALs. After 12 hours of water seal, 13 of the 22 patients’ ALs had stopped, and 3 more sealed by the morning of postoperative day 3. However, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Five of the 6 patients with ALs on postoperative day 4 still had ALs on postoperative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry.

Conclusions. Most ALs after pulmonary resection are expiratory only. A low FEV₁/FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Conversion from suction to water seal is an effective way of sealing expiratory AL, and pneumothorax is rare. If an expiratory AL does not stop by postoperative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Although air leaks are one of the most common problems after pulmonary resection, few studies have been performed on how they are best treated. We observed that large air leaks decrease significantly when chest tubes are taken off of suction and placed to water seal. Based on our experience with lung volume reduction surgery, we theorized that if the lung could remain expanded, air leaks may seal quicker with water seal than with suction. To test this hypothesis, a prospective randomized trial comparing the effects of suction with water seal on air leaks after pulmonary resection was planned. However, because there were no existing data showing the safety of water seal with air leaks in patients without emphysema, our institutional review board asked us to first show that water seal was safe. In response to their request, we developed an algorithm that was applied to the postoperative management of chest tubes. In this protocol we placed chest tubes to water seal in the morning of postoperative day 2 in all patients.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Between July 1, 1996, and April 30, 1997, 101 consecutive patients underwent elective pulmonary resection by a single surgeon (R.J.C.) at The University of Alabama at Birmingham. Patients who had pulmonary resection performed by video thoracoscopy or thoracotomy were included in the trial. Any patient who had lung volume reduction surgery, pneumonectomy, or pulmonary resection with a bronchoplastic procedure or sleeve resection was excluded. All patients had the algorithm shown in Fig 1 applied to the management of their chest tubes. The clinical data of these 101 patients were gathered prospectively.

View larger version (17K): [in this window] [in a new window]   Fig 1. Algorithm used for chest tube (CT) management for air leak (A/L) based on chest roentgenograms (CXR). (POD = postoperative day.)

Pulmonary function testing was performed on all patients and was done on the 2450 Sensormedicus (Anaheim, CA) equipment. Arterial blood gases were also obtained. Patients who had adequate (for their planned procedure) pulmonary function testing performed at outside institutions did not have to repeat the testing, and their incomplete data were excluded from our statistical review.

Operative technique included a double-lumen endotracheal tube and a posterolateral thoracotomy. Standard lung cancer operations were performed, except wedge resections were done in patients whose postoperative predicted diffusing capacity of the lung for carbon monoxide was less than 30% and either their postoperative predicted forced expiratory volume in 1 second (FEV₁) was less than 30%, their preoperative CO₂ was more than 48 mm Hg, or they had significant comorbidities. All staple lines were reinforced with the use of 4-0 Prolene (Ethicon, Somerville, NJ) on an small half needle. Warm sterile water was squirted over the lung to localize air leaks. Patients who underwent upper lobectomy had one anterior straight 28F chest tube placed in the apex and another placed posteriorly. Patients who underwent lower lobectomy had a straight 28F chest tube placed anteriorly in the apex and a 28F right-angle chest tube placed along the diaphragm. Chest roentgenograms were performed daily. All chest tubes were kept on 20 cm H₂O of wall suction until the morning of postoperative day 2. They were then placed to water seal, and another chest roentgenogram was performed about 4 hours later. The algorithm was then followed as outlined in Fig 1. Chest tubes were removed when there was no air leak and the drainage was less then 250 mL day.

Talc slurry was used for patients with air leaks after postoperative day 7. This technique dilutes 2.5 g of asbestos-free talc in 60 mL of sterile normal saline. The solution was vigorously shaken and mixed to prevent any small particles of talc from remaining out of solution and occluding the tube. The chest tube with the leak was disconnected from the drainage system and its end painted with soap. The talc solution was injected into the chest tube with a 60 mL catheter-tip syringe. The chest tube was then irrigated twice with 60 mL of sterile normal saline to prevent clogging. The tube was not clamped. Extension tubing was added to the chest tube and draped over a 6-foot-high intravenous pole, which prevents the talc from leaving the pleural space but allows air to be evacuated.

Operative mortality was defined as any death that occurred during the hospitalization or within 30 days of operation. Late mortality was defined as any subsequent death. Follow-up data were obtained from clinic visits, by telephone interview, or from correspondence from other health care providers. All data are reported with medians and ranges. Univariable comparisons were made using ² and Student’s t tests. Multivariable analysis was performed using logistic regression.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The median age at the time of pulmonary resection in these 101 patients (67 men and 34 women) was 60 years (range, 25 to 87 years). Sixty-three patients had preexisting conditions, which were a previous malignancy in 18, congestive heart failure in 18, hypertension in 16, diabetes in 10, liver transplantation in 3, heart transplantation in 2, and upper extremity fascitis with sepsis, lymphoma, human immunodeficiency virus, pregnancy, Wegener granulomatosis, and pericarditis in 1 each. Fifty-three patients presented with symptoms, which were shortness of breath in 32, fever in 11, cough in 10, chest pain in 5, hemoptysis in 5, and abdominal pain, weight loss, and malaise in 2 each. The indications for operation were a lung nodule or mass in 76 patients, tissue procurement for patients with interstitial lung disease in 12, empyema in 11, and an arteriovenous malformation and aspergilloma in 1 each.

Sixty-nine patients had preoperative pulmonary function tests performed at our institution. These data are shown in Table 1.

Median hospital stay was 5 days (range, 3 to 55 days). There was no difference in the time it took to remove the chest tubes according to the type of procedure performed. Follow-up was complete in all patients (median, 6 months), and none have had a recurrent pneumothorax or empyema. Postoperative complications occurred in 14 patients and were a prolonged air leak in 5 patients, atrial fibrillation in 4, pneumonia in 2, and a superficial wound breakdown, a wound infection, and a pneumothorax after chest tube removal in 1 each. Three of the 5 patients who received talc slurry had a fever. Operative mortality was 3.0% (3 patients). One patient was critically ill from sepsis and had undergone an upper extremity fasciotomy for an ascending hand infection. We performed a decortication because of an empyema, which had failed chest tube drainage and urokinase treatment. He died on postoperative day 55 after being placed on do-not-resucitate orders because of adult respiratory distress syndrome and multiorgan system failure. The second patient underwent a lobectomy for a T2 N2 M0 adenocarcinoma of the lung and had previously undergone radiation treatments for a stage I_E lymphoma. He aspirated on postoperative day 4 and acquired pneumonia and adult respiratory distress syndrome and died on postoperative day 31. The third patient underwent a lobectomy for an unusual T4 N0 M0 atypical carcinoid (four separate nodules all in the right lower lobe). She had a massive pulmonary emboli on postoperative day 4 and died on postoperative day 7.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Formation of air leaks after pulmonary resection is an extremely common problem and can prolong hospitalization. Despite its frequency, there is little objective data on how air leaks should be treated. Most experts believe that wall suction is the best treatment [1–4]. New products are currently being developed to help treat air leaks in the operating room, but some of these are expensive and require special equipment (patches, glues, and sealants). Our goal was to develop a simple, inexpensive system available to all thoracic surgeons to help manage air leaks both in the operating room and postoperatively. We also wanted to develop a classification system that was reproducible, easy to learn, and could help guide treatment.

We currently divide the problem of air leaks into four main categories: (1) preoperative risk factors for their development, (2) intraoperative techniques to prevent them, (3) immediate postoperative techniques to help seal them, and (4) the treatment of persistent ones. This trial statistically analyzed only the first and third category, but it should be stressed that the best way to treat air leaks is to prevent them. As one might expect we found age and some pulmonary function testing that is consistent with increased emphysema to be predictors of having an air leak the day after operation. We reinforced all staple lines with Prolene suture in this study to prevent possible staple line leaks. We also used pericardial strips (Biovascular, St Paul, MN) to reinforce the emphysematous lung, and most importantly, we carefully inspected the lung before closure to pinpoint air leaks and suture them. We do not believe that the normal stapled lung needs suture reinforcement but we did this to all staple lines for consistency in this study.

The approach to air leaks should be systematic. First, one should ensure that the air leak is from the lung and not a system leak. Second, if the patient had a major bronchus that was closed (ie, a pneumonectomy, bilobectomy, lobectomy, or formal segmentectomy) and the leak is quite large and continuous, a bronchopleural fistula needs to be ruled out. We believe that peripheral air leaks are different and should really be called alveolar-pleural fistulas and not bronchopleural fistulas, as the former rarely require reoperation but the latter usually do. In our experience, from patients not presented in this paper, air leaks from bronchopleural fistulas are usually continuous air leaks and are very large. They may be confirmed by bronchoscopy. Once a bronchopleural fistula is ruled out, then the leak can be called an alveolar-pleural fistula, and it should be classified based on both its size and when it occurs in the respiratory cycle. We believe that both of these characteristics affect the rate and chance that an alveolar-pleural air leak may seal.

Despite all preventive measures, air leaks after elective pulmonary resections, as seen in this series (26%), are frequent. They usually occur only during the expiratory phase of the respiratory cycle or with forced expiration (cough). Inspiratory air leaks are extremely unusual. During the period of this study, we treated several patients (not in this study) who transferred to our institution with inspiratory and continuous air leaks. All of these patients required intervention (such as talc slurry) to stop the leak. It appears that expiratory leaks may be more likely to seal without intervention than continuous or inspiratory leaks.

We believe that the apposition of the parietal and visceral pleural is an important element for air leaks to seal. In this series, no patients had a pneumothorax before conversion to water seal, and this probably helped many air leaks seal. For this reason we are still using two chest tubes for lobectomy, especially in the patient who has small leaks that we cannot stop before chest closure with suture because of needle holes. Two patients did, however, experience a pneumothorax on postoperative day 3 after 24 hours of water seal. Both had significant air leaks. Because we believe that pleural–pleural apposition is a crucial component for sealing, we developed our protocol to place these patients to 10 cm H₂O of suction. Our reason for this inherent bias in the protocol was to minimize the amount of suction required, but maintain apposition. Both of these patients’ air leaks were smaller on 10 versus 20 cm H₂O of suction. However, 1 patient continued to have a pneumothorax and required 20 cm H₂O of suction. This did eliminate the pneumothoarx, but the air leak continued and actually increased on the higher suction.

In all patients the size of the leak decreased immediately and dramatically when the chest tube was taken off suction. Water seal stopped the air leak in 60% of patients within 12 hours and in 73% of patients within 24 hours. The obvious criticism of this study is how do we know that all of these leaks would not have sealed if the patient had remained on suction, and how can we say that the size of the leaks decreased without an objective measurement? We believe that our ongoing prospective randomized trial will definitively answer the first criticism, and throughout this new trial we have been using an air leak meter that allows us to grade an air leak on a scale from 1 to 7. We now have objective measurements that document that air leaks do decrease with seal.

As seen in this series, talc slurry is a highly effective way to stop expiratory air leaks that persist after 7 days. Other techniques for persistent air leaks have been tried [5–8]. Many surgeons are circumspect of talc in benign disease or in young patients, but reports have shown the safety of asbestos-free talc [9–17]. Because it seems to be the best and cheapest sclerotherapeutic agent for effusions we see no reason not to use it to achieve sclerotherapy for air leaks. We are not aware of any long-term complications with the use of 2.5 g asbestos-free talc. Although some are hesitant to use talc, there appears to be no data to support this view. We have, however, seen talc reaction, which consists of pleuritis, fever, and a hazy infiltrate of the lung. However the complication of severe pneumonitis and adult respiratory distress syndrome, which we observed on occasion using 7.5 or 10 g talc, has been eliminated using 2.5 g. In our series, if there was an air leak on postoperative day 4, there was a good chance (83%) that it would not seal by postoperative day 7. We now favor early (ie, postoperative day 5) talc pleurodesis in these patients.

In conclusion, most air leaks after pulmonary resections are expiratory only. A low FEV₁ to forced vital capacity ratio, increased age, increased residual volume to total lung capacity ratio, increased residual volume, and an increased functional residual capacity were predictors of an air leak on postoperative day 1. Conversion from suction to water seal of chest tubes is a highly effective way of sealing expiratory air leaks. Pneumothorax is a rare complication from this technique. Talc slurry appears to be an effective treatment for persistent expiratory air leaks [18].

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Robert J. Cerfolio William L. Holman George L. Zorn James K. Kirklin David C. McGiffin Albert D. Pacifico Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cerfolio, R. J. Articles by Pacifico, A. D. Search for Related Content PubMed PubMed Citation Articles by Cerfolio, R. J. Articles by Pacifico, A. D.