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Ann Thorac Surg 2006;82:1052-1056
© 2006 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, The Cardiothoracic Centre, Liverpool, United Kingdom
b Department of Clinical Audit, The Cardiothoracic Centre, Liverpool, United Kingdom
Accepted for publication April 4, 2006.
* Address correspondence to Dr Page, The Cardiothoracic Centre, Thomas Dr, Liverpool, UK L14 3PE. (Email: richard.page{at}ctc.nhs.uk).
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Abstract |
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METHODS: Of 319 lobectomies performed over an 18-month period, 22 patients (6.9%) experienced prolonged air leak (more than 5 days after surgery). Twenty patients consented to be randomly assigned to one of two treatment pathways. The study group received instillation of 120 mL autologous blood into their apical chest drain on the fifth postoperative day, and again if the air leak persisted on days 7 and 9 respectively. No anticoagulation was used for this blood. The control group continued to be treated by tube thoracostomy alone, but if the air leak was still present on the 10th postoperative day they "crossed over" and underwent intrapleural installation of blood as in the study group.
RESULTS: After instillation of blood, the air leak was sealed by the next day in 58.6% of treatments. The median length of air leak was 5 days in the study group and 11 days in the control group (p < 0.001). Time to chest drain removal (median 6.5 days versus 12 days) and hospital discharge (median 8 days versus 13.5 days) were both significantly (p < 0.001) shorter in the study group.
CONCLUSIONS: This technique is effective in sealing air leaks after lobectomy. It allows earlier chest drain removal and shortens hospital stay.
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Introduction |
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The injection of autologous blood into the pleural space in an attempt to seal prolonged air leaks is a simple, painless, and inexpensive treatment. We have been using it as one of our standard methods of managing this clinical situation for many years. However, there is only limited evidence that the technique is truly beneficial [2]. We set out to undertake a randomized study to determine the value of this technique in treating prolonged air leaks after pulmonary lobectomy.
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Material and Methods |
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In the control group, tube thoracostomy alone was continued until the air leak sealed or until the 10th postoperative day. Because of our belief that intrapleural blood instillation was beneficial, we were keen that patients in the control group were not denied its potential benefits if they still had an air leak at this time. Therefore, those control group patients who still had an air leak on the 10th postoperative day were allowed to cross over and receive intrapleural injection of autologous blood if it was considered to be appropriate. This procedure was to be repeated on the 12th and 14th postoperative days if the air leak was still present.
All other aspects of the patients' management were standardized. Information regarding smoking status, history of background lung disease, and spirometry was collected before surgery in all patients. Nonbuttressed linear staplers were used to divide fissures when incomplete. Neither sealants nor pleural tents were used during surgery. All patients had two pleural drains inserted, one basal and one apical, which were both connected to underwater seals. The basal drain was removed on the day after surgery. The apical drain was removed when there was no air leak. Low-grade suction (minus 5 kPa) was applied selectively to the drainage system if the lung failed to expand to fill the pleural cavity on chest radiography. The latter were arranged on a daily basis. The presence of fever, leucocytosis, pleural effusion, empyema, and drain site infection were noted.
Technique of Intrapleural Instillation of Autologous Blood
Using an aseptic technique, a 3/8-inch connector with a luer-lock side port is inserted between the pleural drain and the tubing leading to the underwater seal. The drain tubing is raised 60 cm above its site of entry into the patient by suspending it from a drip stand. Venous blood, 120 mL, is then taken from the patient using a 19G cannula into two 60-mL Luer-lock syringes and immediately injected through the Luer-lock connector through the drain into the pleural cavity. No anticoagulation for the blood is used (otherwise the blood would not clot within the pleural space), so it has to be injected into the drain within as short a time as possible. Using the Luer-lock system described, this is easy to achieve within a few seconds. Indeed, the principal time when the blood might clot before injection is in withdrawing the blood from the patient, which takes on the order of a minute per 60-mL syringe. The elevated drain tubing prevents the intrapleural blood from escaping from the chest but allows continued drainage of air, and if suction is being applied to the chest drain, this can continue also. The patient remains in bed, moving position every 15 minutes for 2 hours in an attempt to distribute the blood evenly throughout the pleural cavity (left and right decubitus, Trendelburg and Fowler positions for 15 minutes each). The drain tubing support is then removed.
A doctor blinded as to the nature of the patients' treatment assessed for the presence or absence of an air leak and also its magnitude on a daily basis both before and after randomization until the drains were removed. Air leaks were classified as 0 (no air leak) through to 3 (large air leak on gentle respiration) as shown in Table 1. We chose not to measure the size of air leaks directly with flow meters as we have limited experience of their use. However, although flow meters may give a more objective estimate of the size of the air leak, we were more interested in the practical issue of whether there was an air leak present or not and whether our patients still required a drainage tube. Thus, the primary endpoints of the study were time to seal off the air leak, time to drain removal, and time to hospital discharge (all expressed as days with respect to the day of surgery).
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The durations of air leak, chest drainage, and hospital stay were expressed as median with interquartile range. The frequency of an effective seal and incidence of complications were expressed as percentages with 95% confidence limits (CL). Differences between groups were explored using a Wilcoxon rank sum test for continuous variables and a 
2 test for categorical variables. Differences were considered significant if the p value was less than 0.05. All results were analyzed using SAS for Windows Version 8 (SAS Institute, Cary, North Carolina).
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Results |
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At a median follow-up of 13 months, no patient had a pneumothorax, empyema, or any other complication that could be attributed to the intrapleural instillation of autologous blood.
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Comment |
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The instillation of autologous blood into the pleural cavity to obliterate an air leak is thought to work by two methods: (1) coagulated blood adheres to the lung as a patch and seals the air leak directly; and (2) blood causes inflammation and subsequent adhesions between the lung and pleura, and the adhesions are responsible for sealing the air leak. The latter of these methods has proved to be incorrect in an animal model [5]. We therefore suggest the term "blood pleurodesis" should not be used to describe this technique, as it does not work by causing a pleural symphysis.
After lobectomy, most small air leaks are from the raw surface of pulmonary parenchyma at the site of dissection of the fissure and are therefore amenable to treatment by a substance applied to the outer surface of the lung perioperatively. Macchiarini and coworkers [6] describe the ideal sealant as one that is not immunogenic, allows for expansion, is adherent to the lung tissue, and should be strong enough to remain sealed. We would contend that autologous blood may well fulfil these criteria.
Nevertheless, for postoperative air leaks, there can be little control of where autologous blood injected into a chest drain is distributed within the chest. In an attempt to increase the chances of the damaged part of the lung becoming covered with blood, we use 120 mL blood compared with the 50 mL described by Dumire and coworkers [4] and Cagirici and associates [7]. To aid in the distribution of blood throughout the pleural cavity, Cagirici describes the positioning of the patient in the left decubitus, right decubitus, Trendelburg, and Fowler positions for 30 minutes each. We adopted a similar protocol for our study. However, we are unsure of the necessity of this, as it has been shown with radiolabelled tetracycline that distribution of this substance is uniform within seconds of instillation within the pleural cavity [8]. Also given that the clotting time of blood is 3 to 8 minutes, any further distribution is unlikely to occur after this time.
Our incidence of prolonged air leaks is similar to that described by others [1, 2], although in the present study a prolonged air leak was defined as an air leak that persists up to the fifth postoperative day. Other authors have defined an air leak as one that is present 7 days after the initial operation. We chose to use 5 days as our definition as it is our routine to discharge our patients home approximately 7 days after their surgery and we believed that an air leak present on the fifth postoperative day would be likely to delay discharge.
The timing of the instillation of blood is controversial. Although Riva de Andres and colleagues [2] suggest leaving it to the ninth postoperative day, we prefer to carry it out on the fifth postoperative day to minimize hospital stay. Also, it is intuitive that the longer the chest drain has been in-situ, the greater the likelihood of colonization of the chest tube with bacteria and hence the exacerbation of infection in the pleural space when performing the instillation of autologous blood.
We found that the instillation of blood was successful in sealing the air leak by the next day in 17 of the 29 occasions it was used. There was a trend toward greater immediate success in the study group in which the blood instillation was performed earlier; 64.3% air leaks sealed by the next day in the study group compared with 53.3% in the control group, in which the instillation of blood was not performed until the 10th postoperative day. Our success rate is lower than the 78% described by Cagarici and associates [7], although their analysis of success was at 48 hours after blood instillation and a different patient population was studied. Cagarici and associates described the technique in patients with spontaneous pneumothorax, whereas all our patients had a lobectomy, and they made no comment on the timing of intervention. It may well be that blood instillation earlier after the initial injury to the lung is more successful in sealing the leak, as the blood may be more likely to adhere to the damaged lung and form a clot at this time.
The intrapleural instillation of autologous blood was well tolerated by all patients although the technique has been linked with fever, pleural effusion, empyema, and tension pneumothorax. These problems can occur in any patient after lobectomy, and the incidence of all complications increases if a prolonged air leak is present [1]. Apart from the single patient who developed a minor empyema, there were no complications that could be attributed to the intrapleural instillation of autologous blood. No patients had a tension pneumothorax after the procedure.
Nevertheless, the possibility of exacerbating any intrapleural infection by the instillation of autologous blood into the pleural cavity needs to be borne in mind. The procedure should be carried out under strict asepsis technique. We would not perform the procedure if the patient had any evidence of wound or chest infection. A large series of patients would be needed to assess whether empyema is in fact a complication of the procedure or a complication of the original operation.
Although we believe we have demonstrated beyond doubt that the intrapleural instillation of autologous blood is successful in the treatment of a prolonged air leak after lobectomy, our small study was not powered to determine the optimum timing and volume of blood used in the procedure.
In conclusion, intrapleural instillation of autologous blood is effective in sealing a prolonged air leak after lobectomy, and leads to a shorter duration of chest drainage and a shorter hospital stay. The procedure is safe and well tolerated.
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