1. science
2. medicine
3. surgery

Management of Prolonged Air Leak and BPF
34th Annual APACVS Winter Meeting
John Howington M.D.
Division Head of Thoracic Surgery
NorthShore HealthSystem
Clinical Associate Professor of Surgery
University of Chicago, Pritzker School of Medicine
Objectives
1. Describe the safe and effective management of a
postoperative air leak.
2. Discuss the management of a prolonged
postoperative air leak.
3. Discuss the difference between parenchymal air
leak and a bronchopleural fistula.
4. Review management strategies for postoperative
bronchopleural fistula.
Prolonged Air Leak (PAL) Definition
Controversy remains on whether ≥ 5 days or ≥ 7 days
Most US groups today define a prolonged air leak
(PAL) as one lasting ≥ 5 days after the operation.
Most European trials define PAL as ≥ 7 days
Reported incidence is widely variable 6 – 20%
“Sex differences in early outcomes after lung
cancer resection: Analysis of the Society of
Thoracic Surgeons’ General Thoracic Database”
Tong et al J Thorac Cardiovasc Surg. 2014 July ; 148(1): 13-18
STS General Thoracic Database was queried for all patients
undergoing pulmonary resection of lung cancer between
2002 and 2010.
Postoperative complications were analyzed with respect to sex.
34,188 patients (17,545 female and 16,643 male)
“Sex differences in early outcomes after lung
cancer resection: Analysis of the Society of
Thoracic Surgeons’ General Thoracic Database”
Tong et al J Thorac Cardiovasc Surg. 2014 July ; 148(1): 13-18
PAL>>BPF
JTCVS April 2013
Prospective collection of Thoracic Morbidity & Mortality
data for consecutive pulmonary resections (n=352) at Ottawa
Hospital Division of Thoracic Surgery January 2008 to April
2010.
The incidence and severity of burden from PAL were
quantified using their Ottawa Thoracic Morbidity &
Mortality (TM&M) system.
JTCVS April 2013
Primary outcome in this study was rates of
non severe (grade I-II) and severe PAL (grade III-IV)
Secondary outcomes included LOS, additional
adverse events and readmission rates.
The TM&M system was based on the Clavian Dindo
classification system.
Class I = no change in management
Class II = new medical therapy
Class III = major intervention
Class IV = organ failure
Class V = death
The TM&M system grading for PAL.
Class II = original chest tube for > 5 days
Class IIIA = 2nd CT; IIIB = Reoperation
Class IV = ICU and/or Ventilator
Class V = death (No deaths occurred in this series)
JTCVS April 2013
The incidence of PAL was 18% (65/352).
*No Buttresses, tents or sealants were used intraoperatively*
Severe PAL was seen in 5% (17/352).
PAL prolonged the median LOS by 4 days
Lessons
Most PAL are uncomplicated and a nuisance problem.
If you do not take proactive steps to reduce PAL the
rate will be high.
Risk factors for Prolonged Air Leak
1. Emphysema on the CT scan
2. Obstructive COPD
3. Pleural Adhesions
4. Male sex
5. Elderly
A Scoring System to Predict the Risk of Prolonged Air
Leak After Lobectomy
Brunelli et al Ann Thor Surg 2010;90:204-9
658 consecutive pulmonary lobectomy patients from
2000 to 2008 in center A were used to develop a risk
adjusted score predicting incidence of PAL (>5 d)
No sealants, pleural tent or buttressing was used.
The incidence of PAL in the derivation set was 13%.
A Scoring System to Predict the Risk of Prolonged
Air Leak After Lobectomy
Brunelli et al Ann Thor Surg 2010;90:204-9
Risk variables were screened by univariate analysis
and then used in stepwise logistic regression
analysis.
The scoring system was developed by proportional
weighing of the significant predictor estimates
and was validated with 233 patients from 2006 to
2008 at center B.
A Scoring System to Predict the Risk of Prolonged
Air Leak After Lobectomy
Brunelli et al Ann Thor Surg 2010;90:204-9
The scoring system was developed by proportional
weighing of the significant predictor estimates
and was validated with 233 patients from 2006 to
2008 at center B.
A Scoring System to Predict the Risk of Prolonged
Air Leak After Lobectomy
Brunelli et al Ann Thor Surg 2010;90:204-9
Characterization and Prediction of Prolonged Air
Leak After Pulmonary Resection…
Rivera et al Ann Thor Surg 2011;92:1062-8
All lung resections entered in Epithor, the French
national thoracic database between 2004 to 2008
were analyzed.
Data collected between 2004 and 2008 (n = 24,113)
were used to build the model using backward
stepwise variable selection.
Characterization and Prediction of Prolonged Air
Leak After Pulmonary Resection…
Rivera et al Ann Thor Surg 2011;92:1062-8
The 2009 data (n = 6,813) were used for external
validation.
The primary outcome was PAL.
Results of the predictive model were used to propose a
score: the index of PAL (IPAL).
Characterization and Prediction of Prolonged Air
Leak After Pulmonary Resection…
Rivera et al Ann Thor Surg 2011;92:1062-8
Prevalence of PAL after pulmonary resection was 6.9% in
the development data set.
Decreased from 7.7% in 2004 to 6.3% in 2008.
Decreased to 5.7% in the 2009 validation set.
*Buttresses, sealants & tents according to surgeon
practice*
Characterization and Prediction of Prolonged Air
Leak After Pulmonary Resection…
Rivera et al Ann Thor Surg 2011;92:1062-8
In 13,100 lobectomy patients PAL of 8.3%
In patients with pleural adhesion PAL of 10.4%
Upper lobe resection PAL of 9.1%.
Incidence of PAL in 7,653 wedge patients was 3.3%
Characterization and Prediction of Prolonged Air
Leak After Pulmonary Resection…
Rivera et al Ann Thor Surg 2011;92:1062-8
B. Orsini et al EJCTS January 2015
1233 Patients with VATS lung resections (lobe & segment) registered
in the French National GTS database between 2009 -2012.
1037 (84%) lobectomy
196 (16%) segmentectomy
96 patients (7.7%) developed a PAL.
Steps to Avoid Prolonged Air Leak
1. Check for a leak.
2. Divide the fissures with a stapler.
3. Chest tube management
4. Lung Sealant
5. Buttress staple lines
Leak check after LLL resection
Steps to Avoid Prolonged Air Leak
1. Check for a leak.
2. Divide the fissures with a stapler.
3. Chest tube management
4. Lung Sealant
5. Buttress staple lines
Chest Tube Management
Suction vs. Seal
“A Prospective Algorithm for the
Management of Air Leaks after Pulmonary
Resection”
Cerfolio et al, Ann Thorac Surg 1998;66:1726-31
an algorithm for the management of chest tubes
and air leaks was applied prospectively to 101
consecutive patients who underwent elective
pulmonary resection
“A Prospective Algorithm for the Management of
Air Leaks after Pulmonary Resection”
Cerfolio et al, Ann Thorac Surg 1998;66:1726-31
Air leaks were classified as Forced Expiratory only,
Expiratory only, Inspiratory only or Continuous.
All chest tubes were kept on 20 cm of suction until
the morning of POD # 2.
“A Prospective Algorithm for the Management of
Air Leaks after Pulmonary Resection”
Cerfolio et al, Ann Thorac Surg 1998;66:1726-31
“A Prospective Algorithm for the Management of
Air Leaks after Pulmonary Resection”
Cerfolio et al, Ann Thorac Surg 1998;66:1726-31
POD # 1, 26 had ALs and all were expiratory only.
POD # 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.
Leaving 6 patients with air leaks
“A Prospective Algorithm for the Management of
Air Leaks after Pulmonary Resection”
Cerfolio et al, Ann Thorac Surg 1998;66:1726-31
Five of the 6 patients with ALs on postoperative day
4 still had ALs on postoperative day 7.
All 5 were treated by talc slurry through the CT.
All 5 ALs resolved within 24 hours after talc slurry.
Algorithm results Summary
Most air leaks after pulmonary resection are
expiratory only
Conversion from suction to water seal is an
effective way of sealing air leaks and
pneumothorax is rare
If an expiratory air leak does not stop by
postoperative day 4 it will likely persist to day 7
Chest Tube Management
Suction vs. Seal Part II
“ A Prospective Randomized Trial Comparing
Chest Tubes on Wall Suction Versus Water Seal
for Air Leaks After Pulmonary Resection”
Cerfolio et al, Presented at AATS April 20, 1999
Patients were randomized to receive suction or seal to
their chest tubes on post-operative day #2.
On POD # 2, 33 of 144 had an air leak.
Prospective Randomized Trial…
Results
18 randomized preoperatively to seal 15 to suction
67% of air leaks resolved on water seal by POD #3
vs. 7% on suction
all 6 patients whose air leak did not seal had leaks
of 4/7 or greater
13 of the 14 patients converted from suction to
water seal resolved their air leaks by POD #4
Chest Tube Management
Conclusions
Placing chest tubes on water seal is superior to wall
suction for stopping air leaks after pulmonary
resection
Water seal does not stop large (4/7 or >) air leaks
Air leaks present on POD # 4 will probably persist to
day 7
A prospective randomized controlled trial of
suction versus non-suction to the under-water
seal drains following lung resection.
N. Alphonso et al, EJCTS 27 (2005) 391-394
All lung resection patients
June 2002 to February 2004
At the end of the operation all
placed to water seal
Allocation to suction yes/no
after the operation ended
Suction applied in PACU
A prospective randomized controlled trial of suction
versus non-suction to the under-water seal drains
following lung resection.
N. Alphonso et al, EJCTS 27 (2005) 391-394
Patients underwent
unbiased allocation by
minimization.
At the end of the operation
the computer generated
allocation was called to the
PACU.
The surgeons were blinded
to the allocation.
A prospective randomized controlled trial of suction
versus non-suction to the under-water seal drains
following lung resection.
N. Alphonso et al, EJCTS 27 (2005) 391-394
Well matched groups both
for risk factors of
procedure performed and
primary surgeon.
A prospective randomized controlled trial of
suction versus non-suction to the under-water
seal drains following lung resection.
N. Alphonso et al, EJCTS 27 (2005) 391-394
Primary outcome was air leak (time to last bubble seen).
Secondary outcomes:
PAL (AL lasting 6 full days)
A prospective randomized controlled trial of suction
versus non-suction to the under-water seal drains
following lung resection.
N. Alphonso et al, EJCTS 27 (2005) 391-394
PAL beyond 6 days was:
7.8% for suction
10.1% for no suction
A prospective randomized controlled trial of
suction versus non-suction to the under-water
seal drains following lung resection.
N. Alphonso et al, EJCTS 27 (2005) 391-394
Steps to Avoid Prolonged Air Leak
1. Check for a leak.
2. Divide the fissures with a stapler.
3. Chest tube management
4. Lung Sealant
5. Buttress staple lines
Prospective Randomized Study Evaluating a
Biodegradable Polymeric Sealant for Sealing
Intraoperative Air Leaks That Occur During
Pulmonary Resection
Allen MS et al Ann Thor Surg 2006
Multicenter prospective randomized trial
161 Patients randomized 2:1 to receive sealant or
control for at least one significant air leak
(≥ 2.0mm) after pulmonary resection.
Prospective Randomized Study Evaluating a
Biodegradable Polymeric Sealant for Sealing
Intraoperative Air Leaks That Occur During
Pulmonary Resection
Allen MS et al Ann Thor Surg 2006
Intraoperative air leaks were sealed in 77% of the
sealant group compared with 16% in the control
group.
Median length of stay was 6 days in the sealant
group compared to 7 days in the control group.
Surgical Sealant for the Prevention of PAL After
Lung Resection: Meta-Analysis
13 trials were included in the meta-analysis.
Overall 1335 patients allocated to glue or patch (1,064) or
buttress (271) for prevention of prolonged air leak
after lung resection.
In the control group sutures or staples were used
according to routine.
Surgical Sealant for the Prevention of PAL After
Lung Resection: Meta-Analysis
Use of glue or a patch or buttressing decreased PAL.
Pooled effect size odds ratio was 0.55 (95% CI 0.39-0.79)
No influence on postop complications: atelectasis,
pneumonia, pneumothorax and mortality.
8 trials (1,020 patients) decreased atrial arrhythmia was
seen. Odds ratio of 0.44
Treatment of Prolonged Air Leak
1. Discharge with the chest tube.
2. Endobronchial valve placement
3. Reoperation with repair of leak and pleurodesis.
Treatment of Uncomplicated
Prolonged Air Leak
Consider discharge with
the chest tube in place
Options of a Heimlich
valve and a foley bag
or mini drainage
system
Treatment of Uncomplicated
Prolonged Air Leak
Consider discharge with
the chest tube in place
Options of a Heimlich
valve and a foley bag
or mini drainage
system
Treatment of Uncomplicated
Prolonged Air Leak
Consider discharge with the
chest tube in place
Options of a Heimlich valve
and a foley bag or mini
drainage system
Treatment of Prolonged Air Leak
1. Discharge with the chest tube.
2. Endobronchial valve placement
3. Reoperation with repair of leak and pleurodesis.
Endobronchial Valve Treatment for Prolonged Air
Leaks of the Lung: A Case Series
Gillespie et al Ann Thor Surg 2011;91:270-3
Patients with air leaks that persisted after treatment
gave consent and compassionate use approval
was obtained.
Bronchoscopy with balloon occlusion was used to
identify the airways to be treated. IBV Valves were
placed after airway measurement.
Endobronchial valve for Treatment of PAL
Balloon occlusion
Deployed valves
Endobronchial valve for Treatment of PAL
Endobronchial Valve Treatment for Prolonged Air
Leaks of the Lung: A Case Series
Gillespie et al Ann Thor Surg 2011;91:270-3
During a 15-month period, 8 valve placement procedures were
performed in 7 patients and all had improvement in the air
leak.
The median duration of air leakage was 4 weeks before and 1
day after treatment, with a mean of 4.5 days.
Endobronchial Valve Treatment for Prolonged Air
Leaks of the Lung: A Case Series
Gillespie et al Ann Thor Surg 2011;91:270-3
Discharge within 2 to 3 days of
the procedure occurred in 57%
of the patients.
A median of 3.5 valves were
used, and all valve removals
were successful.
There were no procedural or
valve- related complications.
Treatment of Prolonged Air Leak
1. Discharge with the chest tube.
2. Endobronchial valve placement
3. Reoperation with repair of leak and pleurodesis.
Look for the source
VATS Mechanical Pleurodesis
Summary for PAL
1. Consider preoperative risk for PAL and counsel
and plan accordingly.
2. Look for Leaks!
3. Staple, suture , and/or seal leaks in the OR.
4. Consider buttress, tents, etc and/or sealant as
prophylaxis in high risk patients.
Look for the source
Beware of space issues
No leak + no space = No problem
Bronchopleural Fistula (BPF)
Postpneumonectomy Empyema:
Results After the Clagett Procedure
Zaheer et al Ann Thor Surg 2006;82:279-87
A retrospective review of the Mayo Clinic
experience with management of patients with
postpneumonectomy empyema treated by the
Clagett procedure.
Data were analyzed from 84 consecutive patients
from July 1988 to June 2004.
Postpneumonectomy Empyema:
Results After the Clagett Procedure
Zaheer et al Ann Thor Surg 2006;82:279-87
A BPF was present in 55
and closed in all.
In 51 an intrathoracic
muscle flap was used.
10 recurrences (18%), all in
patients with suturing and
muscle flap
Postpneumonectomy Empyema:
Results After the Clagett Procedure
Zaheer et al Ann Thor Surg 2006;82:279-87
3 patients required a 3rd
closure with suturing and
a muscle flap and all
stayed closed.
Op Mortality was 7.1%
Median overall survival
was 3.4 years.
Muscle Flaps
Use of a serratus anterior musculocutaneous flap
for surgical obliteration of a bronchopleural
fistula
Park et al Interactive CardioVascular and Thoracic Surgery (2015) 1–6
A retrospective review of patients with surgical
management of BPF from April 2005 to June 2014
was performed.
A de- epithelized SAMC flap has replaced the
conventional SAM flap since August 2013.
Nine of consecutive former SAM flaps and 5
consecutive later SAMC flaps were identified.
Use of a serratus anterior musculocutaneous flap
for surgical obliteration of a bronchopleural
fistula
Park et al Interactive CardioVascular and Thoracic Surgery (2015) 1–6
All five BPFs treated by SAMC flap were greater
than 1 cm in diameter and all occurred on the
right side.
The leading primary diagnosis of a BPF was lung
cancer, and the 4 lung cancer patients all
underwent previous irradiation.
Use of a serratus anterior musculocutaneous flap for
surgical obliteration of a bronchopleural fistula
Park et al Interactive CardioVascular and Thoracic Surgery (2015) 1–6
Recurrence of the BPF was
noted in 1 patient 6 weeks
after surgery.
In 4 of 5 patients, viable
adipose tissue was
confirmed by CT 6 months
after the operation.
Use of a serratus anterior musculocutaneous flap
for surgical obliteration of a bronchopleural
fistula
Park et al Interactive CardioVascular and Thoracic Surgery (2015) 1–6
Use of a serratus anterior musculocutaneous flap
for surgical obliteration of a bronchopleural
fistula
Park et al Interactive CardioVascular and Thoracic Surgery (2015) 1–6
Use of a serratus anterior musculocutaneous flap
for surgical obliteration of a bronchopleural
fistula
Park et al Interactive CardioVascular and Thoracic Surgery (2015) 1–6
Eloesser Flap
Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 61-69DOI: (10.1053/j.optechstcvs.2010.03.003)
Copyright © 2010 Elsevier Inc. Terms and Conditions
Eloesser Flap
Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 61-69DOI: (10.1053/j.optechstcvs.2010.03.003)
Copyright © 2010 Elsevier Inc. Terms and Conditions
Figure 5
Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 61-69DOI: (10.1053/j.optechstcvs.2010.03.003)
Copyright © 2010 Elsevier Inc. Terms and Conditions
Figure 6
Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 61-69DOI: (10.1053/j.optechstcvs.2010.03.003)
Copyright © 2010 Elsevier Inc. Terms and Conditions
Figure 7
Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 61-69DOI: (10.1053/j.optechstcvs.2010.03.003)
Copyright © 2010 Elsevier Inc. Terms and Conditions
Summary for BPF
1. Known or suspected BPF goes to the operating
room!
2. Repaired bronchial stumps are covered with a
large muscle flap.
3. When possible avoid prolonged mechanical
ventilation.
Questions?