“Air leaks” after pulmonary resection. Roberto A. Salas Fragomeni, MD

Introduction Air leaks can be iatrogenic, traumatic or post-resectional Most common complication after pulmonary resection.

Incidence Extremely common, 20 – 33% after elective pulmonary resection. 4.5 – 45% After Pneumonectomy 0.5 – 10 % After Lobectomy 8% after segmental or wedge resection Cerfolio RJ, Ann Thorac Surg, 2002 Louis M et al, CHEST, 2005

Risk Factors Wound healing issues Large resections Nutritional status steroid use cancer surgery Large resections Lobectomy Bi-lobectomy cancer resections Cerfolio RJ, Ann Thorac Surg, 2002 Louis M et al, CHEST, 2005

Definition Alveolar-Pleural Fistula Bronchopleural fistula

Initial Evaluation Verify air leak is not a “system” leak. Check system connections Classify: Qualitative and quantitatively - Robert David Cerfolio (RDC) classification.

Initial Evaluation Qualitative - 4 types: Continuous (C) - MV Inspiratory (I) - MV and emphysema. Expiratory (E) – Most common post pulmonary surgery Forced Expiration (FE) – Only with coughing Leak in resolution

Initial Evaluation Quantitative Small to large (1 – 7 respectively).

Initial Evaluation Prolonged Air leak Definition varies Usually defined as air leak for more than 3 to 7 days post op Cerfolio et al, Ann Thorac Surg, 2002 Cerfolio, Curr Op Pulm Med, 2005 Nason KS, Schwartz’s Principles of Surgery, 9e, 2010

Initial Evaluation Risk for Prolonged air leak – Leak will be present for > 3 days post-op: E4 or greater air leak E6 or greater on POD 1 > FE3 on day 3 Others: Expanding pneumothorax Subcutaneous emphysema Cerfolio RJ, Ann Thorac Surg, 2002 Francesco L et al, CHEST, 2006

Initial Evaluation Bronchoscopy is the gold standard for diagnosis methylene blue staining, Xe ventilation study CT scanning Francesco L et al, CHEST, 2006

Management Bronchial vs Parenchymal leak Blood patch Pleurodesis Thoracostomy tube drainage (chest tube management) Bronchoscopic approach Surgical repair

Blood Patch ~ 50 mL autologous blood Initiates and supports fibrinous and inflammatory response No supporting evidence vs Placebo Douglas et al, Clinic in Chest Medicine, 2010

Heimleich Valve or Portable CT Consider if Leak is E3 or Less Place POD 3~ CXR 24 hours after placement Rule out SQ emphysema and pneumothorax. Discharge POD 4 or 5 Weekly XRAY Remove when air leak resolves or air leak present after 2 weeks* Cerfolio et al, Ann Thorac Surg, 2002 Cerfolio, Curr Op Pulm Med, 2005

Bronchoscopic approach For Fistulas of < 4 mm Not recommended by ACCP Glues or adhesives: fibrin, albumin, glutaraldehyde, or acrylic, Gel foam or cellulose, Ethanol, Antibiotics, Metal coils, Decalcified spongy calf bone, Watanabe spigots, Cautery, Laser 38 – 50 % air leak reduction or control Douglas et al, Clinic in Chest Medicine, 2010

Thoracostomy tube drainage Wall suction best management (?) Water seal for most air leaks will decrease alveolo-pleural fistulas Avoid suction if possible or use lowest setting that will resolve pneumothorax Cerfolio, Curr Op Pulm Med, 2005

Surgical Approach Indications: E6 or greater POD1 If fistula fails to close >3 weeks after conservative management (Nutritional support, chest tube) Broncho-pleural fistula Re-suture and reinforcement of bronchial stump (Pericardial, omental, latissimus, intercostal flaps) Pleural Tenting Success rate: 80 – 95% Sutures preferred over staples Stamatis G et a. Thorac Cardio Surg , 1994 Hollaus PH, Eur J Cardiot Surg , 1999

Conclusion Air leaks are a common complication after pulmonary resections. Continuous air leaks or Expiratory air leaks with high volume should prompt evaluation for bronchial leaks Air leak Management varies according to the air leak classification and can be conservative or surgical. Broncho-pleural fistulas usually require prompt reoperation for resuturing and/or buttressing of the bronchial stump.