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

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

3. 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

4. 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

5. Definition
Alveolar-Pleural Fistula
Bronchopleural fistula

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

7. 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

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

9. 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

10. 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

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

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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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.