Elsevier

The Annals of Thoracic Surgery

Volume 66, Issue 5, November 1998, Pages 1726-1730
The Annals of Thoracic Surgery

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

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
https://doi.org/10.1016/S0003-4975(98)00958-8Get rights and content

Abstract

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.

Section snippets

Patients and methods

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

Results

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.

Comment

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, 2, 3, 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,

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