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Ann Thorac Surg 2000;70:270-272
© 2000 The Society of Thoracic Surgeons

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Original articles: General thoracic

Postsurgical pleurodesis with autologous blood in patients with persistent air leak

^a Thoracic Surgery Service, Hospital "Juan Canalejo", A Coruña, Spain

Address reprint requests to Dr Rivas de Andrés, Cirugía Torácica, Hospital Miguel Servet, Isabel La Católica 1, 50009 Zaragoza, Spain
e-mail: jjrivas{at}jet.es

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
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.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
One of the most common problems encountered by thoracic surgeons is persistent air leak. It can be managed conservatively with a chest tube, with or without aspiration, the application of a Heimlich valve, or a surgical procedure to seal the leak. The duration of conservative management ranges from 5 days to 3 weeks depending on the team’s experience. Before resorting to surgical intervention, most authors advocate the use of pleurodesis. Almassi and Haasler [1] described a successful technique for chemical pleurodesis with tetracycline. Biological glues of the Tissucol type (Baxter AG/Immuno AG, Vienna, Austria) are in frequent use. Other agents known to cause pleural adhesions are silver nitrate, talcum powder, and quinacrine hydrochloride. Although Dumire and coworkers [2] reported good results with the autologous blood patch technique, it is not commonly used [3–6]. We report the case of pleurodesis with autologous blood postoperatively in persistent air leak in 6 patients with non–small cell lung cancer.

	Material and methods

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The study group comprised 6 patients who had operation for non–small cell lung cancer between 1993 and January 1998 in our unit (Table 1). The mean age was 55 years (range, 36 to 66 years), and all were men. Pleurodesis with autologous blood was performed after persistent air leak of more than 10 days. The procedure was carried out on the ward at bedside under aseptic conditions (surgical scrub, mask, sterile gown, and gloves). No sedation or analgesia was required. A sample of peripheral blood was taken from the patient’s arm. The chest tube (28F usually) was clamped and disconnected from the waterseal only momentarily, its distal end was prepared with povidone-iodine, and 50 to 250 mL of blood was introduced by attaching the cone of the syringe to the tube. Heparin was not added. The chest tube was kept 60 cm above the patient’s chest [1] for safety with waterseal drainage of any persistent pneumothorax. The patient’s position in bed was changed during the day to help distribute the blood in the cavity. The following day, the waterseal drainage was reviewed for the presence of air leak, and a forced-expiration conventional chest radiograph was made before and after removal of the tube. Follow-up of all patients was continued on an out-patient basis.

	Results

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There was no infection of the pleural cavity or other morbidity. Mean follow-up was 26.1 months (range, 1 to 55 months).

One patient died of cerebral metastasis 50 days after pleurodesis. The other 5 patients are still alive.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The existence of a persistent air leak in patients with pneumothorax occurring spontaneously, traumatically, or after lung operation, is one of the most common problems encountered by thoracic surgeons. It is frequently treated by prolonged aspiration through a chest tube, use of a Heimlich valve, or repeat thoracotomy. Before resorting to surgical treatment, especially in patients in poor condition overall, most authors recommend pleurodesis with different agents, the most popular being tetracycline [1] and, more recently, biological glues such as Tissucol. Chemical pleurodesis is usually performed after the air leak has stopped. Almassi and Haasler [1] described a technique for and their subsequent experience with tetracycline pleurodesis in the presence of a persistent air leak. Tetracycline pleurodesis works probably by inducing an inflammatory reaction and scarring, with no "patch" effect, and causes a gradual cessation of the air leak.

Autologous blood has been used for pleurodesis in recurrent and chronic spontaneous pneumothorax for a number of years [2–5]. However, the experiences reported in the literature are limited to two studies [3, 5]. One [3] involved 25 patients with recurrent and chronic pneumothorax caused by an adhesion holding a bulla open. The success rate for autologous blood pleurodesis was 84% (21 of 25 patients). The other study comprised 14 patients with recurrent pneumothorax secondary to bulla, and the results were especially encouraging [5]. The pathophysiologic mechanism by which the blood achieves pleurodesis could involve two factors working together: the blockage of a small air leak and the fibrogenic activity of the blood in the pleural cavity producing inflammation and irritation of both pleurae [3]. Other authors [6] have used this kind of pleurodesis with variable results in patients with ambulatory peritoneal dialysis and persistent hydrothorax. We know of only one case in the literature of a patient operated on for persistent leak after middle lobectomy and atypical resection of the upper right lobe for non–small cell lung cancer [2].

We obtained a success rate of 100% in our 6 patients at low cost and with no morbidity associated with the procedure. No sedation was required for blood pleurodesis. In the series reported by Robinson [3], one pleural infection was due to autologous blood pleurodesis (an incidence of 4%). Our patients had no pleural infections. Heparin was not added. The thoracostomy tube was clamped and disconnected from the waterseal drainage only for a moment before instillation of the blood. It was then reattached to the waterseal; air could escape, but the blood remained in the pleural cavity to exert its effect. Although the amount of autologous blood ranged from 50 to 250 mL, we consider 100 mL sufficient to produce the desired effect. In addition, autologous blood should be given only once or as few times as necessary. We recommend the use of autologous blood in cases of persistent air leak of more than 8 to 10 days’ duration, especially in patients in poor general condition, and only when this is neither accompanied nor to be followed by more aggressive management. In light of these preliminary findings demonstrating the safety and the efficacy of this procedure, we think further randomized clinical trials of pleurodesis as treatment are needed.

	References

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1. Almassi G.H., Haasler G.B. Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg 1989;47:786-787.[Abstract]
2. Dumire R., Crabbe M.M., Mappin F.G., Fontenelle L.J. Autologous "blood patch" pleurodesis for persistent pulmonary air leak. Chest 1992;101:64-66.[Abstract/Free Full Text]
3. Robinson C.L. Autologous blood for pleurodesis in recurrent and chonic spontaneous pneumothorax. Can J Surg 1987;30:428-429.[Medline]
4. Mallen J.K., Landis J.N., Frankel K.M. Autologous "blood patch" pleurodesis for persistent pulmonary air leak. Chest 1993;103:326-327.[Medline]
5. Blanco Blanco I., Canto Argiz H., Carro del Gamino F., Fuentes Vigil J., Sala Blanco J. Pleurodesis with the patient’s own blood. Arch Bronconeumol 1996;32:230-236.[Medline]
6. Catizone L., Zuchelli A., Zuchelli P. Hydrothorax in a PD patient. Adv Perit Dial 1991;7:86-90.[Medline]

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