Persistent air leaks: a review with an emphasis on bronchoscopic management

Abstract

Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.

Management of Persistent Air Leaks Using Endobronchial Autologous Blood Patch and Spigot Occlusion: A Multicentre Randomized Controlled Trial in China

“…Under these circumstances, bronchoscopic techniques have been among the therapeutic options for decades [3, 7]. The endoscopic approach is particularly attractive because of its relatively low invasiveness, which is of great value especially for PAL patients who are at high surgical risk.…”

“…Air leaks can be caused by either an alveolar-pleural fistula (APF) or bronchopleural fistula, of which APF is the most common. APF is a communication between the alveoli and pleura, whereas bronchopleural fistula is defined as a communication between the bronchus and pleura [3, 4]. Patients with SSP can be initially managed with chest tube-attached water-seal drainage (CTD) [5, 6].…”

“…Patients with SSP can be initially managed with chest tube-attached water-seal drainage (CTD) [5, 6]. However, despite 5–7 days of CTD, many patients may still develop persistent air leaks (PALs) [3, 5, 7]. The presence of PALs is associated with significant morbidity, prolonged hospital stay, and increased health care costs [8, 9].…”

Treatment of Persistent Air Leak with Endobronchial Valves

“…Persistent air leaks are usually treated conservatively with prolonged thoracostomy tube drainage [1,2,5]. In case this approach fails, surgical revision used to be the only option.…”

“…[1]. Consequently, during the past few decades, numerous minimally invasive techniques have been developed ranging from pleurodesis with chemicals or blood components, to bronchoscopic techniques using coils, stents, antibiotics, ethanol and several other glues or adhesives [5]. However, controlled studies showing consistent efficacy are lacking.…”