Reference
Study design and period
Population
Definition persistent air leak
Air leak treatment intervention
Duration tube with PAL and intervention
Complications reported
Quality evidence rank
Brunelli et al. [1]
Retrospective review
n = 558 pulmonary resections
>7 days
Heimlich valve
Air leak cessation
None related to Heimlich
Moderate
Jan 1995–Jun 2003
n = 32 with persistent air leak discharged on Heimlich valve
13 within 3 weeks
12 within 4 weeks
7 within 2 months
Cerfolio et al. [2]
Retrospective review
n = 669 pulmonary resections
>4 days
Heimlich valve
17 air leak resolved POD#7 and tube removed
Prior to discharge
Moderate
n = 33 with persistent air leak following lobectomy, segmentectomy, wedge resection
9 with airleak at POD#14 admitted for provocative clamping and tube removed POD#15
6 pneumothorax and subcutaneous emphysema on Heimlich prior to discharge (all airleaks > 5)
After discharge
1 chest tube accidental removal POD#12, remained out
Cerfolio et al. [3]
Retrospective review
n = 6,038 pulmonary resections
>4 days
Heimlich valve
Follow-up median of 16.5 days from discharge with Heimlich
None related to Heimlich
Moderate
Jul 2000–Jul 2007
n = 199 with persistent air leak discharged on Heimlich valve
144 tube removed if no pneumothorax on CXR regardless of air leak
14 with pneumothorax on CXR admitted for provocative clamping regardless of air leak; all tubes removed the next day
Liberman et al. [4]
Retrospective case-control
n = 1393 pulmonary resections
>5 days
Observation (n = 33)
Mean duration Heimlich not reported
1 readmit for pneumothorax
Very low (regarding Heimlich)
n = 78 with persistent air leak after Lobectomy or bilobectomy by thoracotomy
Pleurodesis (n = 41)
Overall mean duration chest tube 11.5 days
1997–2006
Talc (n = 30), bleomycin (n = 1), doxycycline (n = 7), minocycline
Heimlich
(n = 3)
Reoperation –muscle flap (n = 1)
1 empyema with death after talc
Moderate (regarding chemical pleurodesis)
Rieger et al. [5]
Retrospective review
n = 457 major thoracic procedures
Not defined
Express mini 500 (Atrium Medical Corp, Hudson, NH)
Mean duration tube 11.2 days
1 readmit for pneumothorax
Moderate
May 2003–Dec 2004
n = 36 with persistent air leak after postlobectomy, segmentectomy, wedge resection, pleurodesis, pericardial window, mediastinal dissection or esophagogastrectomy
1 empyema
1 cellulitis
1 underwent talc slurry POD#55
No death
No pneumonia
Tcherveniakov et al. [6]
Retrospective review
n = 74 cases of outpatient tube management
Not defined
One-way valve drainage system with soft fluid reservoir
Mean duration tube 19.56 days
6 cellulitis
Moderate
4 readmission:
Nov 2009–Nov 2010
n = 43 with persistent air leak following VATS or open lobectomy, wedge, or decortication
1 tube reinsertion for pneumothorax
3 Empyema
Rahman et al. [7]
Retrospective review
n = 98 who underwent bullectomy for recurrent spontaneous pneumothorax; pneumostat applied to all patients regardless of air leak
Not defined
Pneumostat (Atrium Medical Corp, Hudson, NH)
Mean hospital
4 cellulitis
Moderate
Stay 3.08 days
Mean duration tube 7.5 days
Lodi and Stefani [8]
Retrospective review
n = 248 pulmonary resections
>6 days
One-way valve drainage system
Mean duration tube 11.5 days
No death
Moderate
No empyema
Mar 1998–Mar 1999
n = 18 with persistent air leak after lobectomy, wedge resection
No pneumonia
No SC emphysema
Ponn et al. [9]
Retrospective review 1990–1997
n = 240 cases of outpatient tube management
Not defined
Heimlich valve
Mean duration Heimlich 7.5 days
1 admit for suction due to SC emphysema
Moderate
n = 45 outpatient management with persistent air leak after lobectomy, wedge resection
McKenna et al. [10]
Retrospective review
n = 107 LVRS
>5 days
Heimlich valve
Mean duration Heimlich 7.7 days
No death
Moderate
n = 25 with persistent air leak after lung volume reduction surgery
No empyema
Nov 1994–Jul 1995
No pneumonia
Table 17.2
Studies reporting the efficacy of chemical sclerosis in management of persistent air leak
Reference | Study design and period | Population | Definition persistent air leak | Air leak treatment intervention | Duration tube with PAL and intervention | Complications reported | Quality evidence rank |
|---|---|---|---|---|---|---|---|
Liberman et al. [4] | Retrospective case-control 1997–2006 | n = 1,393 pulmonary resections | >5 days | Observation (n = 33) | Successful sclerosis in 40 of 41 patients with persistent air leak (97.6 %) | 1 readmit for pneumothorax | Moderate |
n = 78 with persistent air leak after Lobectomy or bilobectomy by thoracotomy | Pleurodesis (n = 41) | Mean duration air leak post sclerotherapy was 2.8 days | 1 mycocutaneous flap for persistent air leak after talc pleurodesis | ||||
Talc (n = 30), bleomycin (n = 1), doxycycline (n = 7), minocycline (=1) | 1 empyema after talc pleurodesis with death | ||||||
Heimlich (n = 3) | Overall mean duration chest tube 11.5 days | ||||||
Reoperation –muscle flap (n = 1) |
Table 17.3
Studies reporting the efficacy of autologous blood patch in management of persistent air leak
Reference | Study design and period | Population | Definition persistent air leak | Air leak treatment intervention | Duration tube with PAL and intervention | Complications reported | Quality evidence rank |
|---|---|---|---|---|---|---|---|
Shackcloth et al. [15] | Prospective randomized study over 18 months | n = 319 lobectomy | >5 days | 120 mL autologous venous blood pleurodesis | Significant reduction in duration chest tube (6.5 vs 12 days, p < 0.001) | 1 empyema requiring pleural catheter insertion and antibiotics | Moderate |
n = 20 with persistent air leak after lobectomy | # of pleurodesis sessions to stop air leak | No deaths | |||||
7 required 1 | |||||||
2 required 2 | |||||||
1 required 3 | |||||||
Control group | |||||||
8 of 10 still had air leak POD#10 | |||||||
Oliveira et al. [16] | Retrospective review | n = 27 with persistent air leak treated with autologous blood | Not defined | Up to 200 ml (depending on pleural cavity size) | 23 (85 %) successful pleurodesis | 1 empyema (not in patient with history empyema) | Moderate |
Jan 2001–Aug 2008 | n = 10 after lobectomy | Autologous blood pleurodesis | 1 unsuccessful pleurodesis post lobectomy | 1 fever | |||
n = 9 after spontaneous pneumothorax | 6 required 2 pleurodesis sessions | ||||||
n = 4 after bullectomy | Mean time to fistula resolution after pleurodesis was 1.5 days | ||||||
n = 2 decortication | |||||||
n = 1 after lung biopsy | |||||||
n = 1 empyema | |||||||
Andreetti et al. [17] | Retrospective case control | n = 25 persistent air leak patients after lobectomy | >6 days | Autologous blood pleurodesis | Air leak stopped sooner after pleurodesis than controls; and sooner with 100 ml vs 50 ml (2.3 vs 1.5 days, p = 0.005) | No infection | Moderate |
Group A: n = 12, 50 ml | n = 12, 50 ml | Group C airleak stopped later (12.3 days postop, p = 0.0009, and 0.0001) | No deaths | ||||
Group B: n = 13, 100 ml | n = 13, 100 ml | No early or late side effects | |||||
Group C: controls, 15 last patients with persistent air leak | |||||||
Droghetti et al. [18] | Retrospective review Jan 1999–Feb 2006 | n = 21 persistent air leak after pulmonary surgery | >7 days | 50 to 150 ml Autologous Blood pleurodesis | 17 (81 %) had air leak resolution rate in the first 24 h of pleurodesis | 1 fever (decortication patient) | Moderate |
n = 13 lobectomy | N = 2, 50 ml N = 6, 100 ml | 4 required a 2nd pleurodesis 36 h after first | No empyema or other early or late side effects | ||||
n = 1 bilobectomy | N = 13, 150 ml | Chest tubes removed 48 h after air leak cessation | |||||
n = 2 decortication for empyema | |||||||
n = 5 LRVS | |||||||
Lang-Lazdunski and Coonar [19] | Retrospective review | N = 196 lung resections | >7 days | N = 11 with 50 ml autologous blood pleurodesis | All 11 (100 %) air leak cessation | After pleurodesis | Moderate |
Jan 2002–Jan 2004 | N = 13 with persistent air leak after lobectomy, bi-lobectomy or wedge | N = 2 Heimlich valve | –8/11 (72.7 %) within 12 h | Reported no empyema, but 1 pleural fluid culture was S. aureus positive | |||
–3 within 48 h | 1 pneumonia | ||||||
Time to airleak resolution with Heimlich not reported | 2 fever | ||||||
Rivas de Andrés et al. [20] | Retrospective review | n = 6 underwent | >10 days | 50 to 250 ml autologous blood pleurodesis | All 6 (100 %) success 24 h after pleurodesis
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