Optimal management of long-term air leakage after lung resections for cancer

Lung resection is the main diagnostic and therapeutic surgical intervention in terms of lung cancer management. Air leak through pleural drains often occurs after lung resections due to damage to the pulmonary parenchyma. Therefore, proper drainage of the pleural cavity is very important for the successful outcome of the operation. The installation of a single pleural drainage after anatomical resection, the refusal to use vacuum aspiration and the earliest possible removal of drains contribute to the rapid activation of patients in the postoperative period. Prolonged air leakage (PAL) after lung resection, on average, develops in 15 % of lung cancer patients, remaining one of the most common complications adversely affecting the rehabilitation of patients and leading to delayed discharge from the hospital. The incidence of empyema with prolonged air leakage is 10.4 % with air discharge for more than 7 days compared to 1 % with air leaks less than or equal to 7 days. PAL requires prolonged drainage of the pleural cavity, which increases postoperative pain, causing shallow breathing, difficulty coughing leads to an increased risk of pneumonia, decreased mobility is accompanied by a high risk of thromboembolic complications. In addition, the treatment of complications is associated with the need to perform additional invasive interventions such as chemical or mechanical pleurodesis. Prolonged air leakage is associated with an increase in hospital mortality. Patients with an air leak have a 3.4 times greater risk of death than patients without it. Active tactics in relation to PAL include preoperative prediction of a high risk of complications, intraoperative measures to prevent air leak from the lung parenchyma and postoperative treatment to reduce the duration of PAL. The urgency of the problem is due to the fact that prolonged air leakage in patients with lung cancer after organ-preserving operations is associated with an increased risk of infectious complications due to the need for prolonged drainage of the pleural cavity. In this review, the main attention is paid to two components of postoperative management of PAL: diagnosis with an accurate assessment of the intensity of air leak and treatment of alveolar-pleural fistulas.

1. Gilbert S, McGuire AL, Maghera S, Sundaresan SR, Seely AJ, Maziak DE, et al. Randomized trial of digital versus analog pleural drainage in patients with or without a pulmonary air leak after lung resection. J Thorac Cardiovasc Surg. 2015 Nov;150(5):1243– 1249. https://doi.org/10.1016/j.jtcvs.2015.08.051

2. Petrella F, Spaggiari L. Prolonged air leak after pulmonary lobectomy. J Thorac Dis. 2019 Sep;11(Suppl 15):S1976–S1978. https://doi.org/10.21037/jtd.2019.07.49

3. Kozower BD, LoCicero J, Feins RH, Colson YL, Gaetano R. Shields’ general thoracic surgery. 8th edition. Philadelphia: Lippin- cott Williams & Wilkins; 2019, 573–585 p.

4. Attaar A, Winger DG, Luketich JD, Schuchert MJ, Sarkaria IS, Christie NA, et al. A clinical prediction model for prolonged air leak after pulmonary resection. J Thorac Cardiovasc Surg. 2017 Mar;153(3):690–699.e2. https://doi.org/10.1016/j.jtcvs.2016.10.003

5. Gómez-Caro A, Roca MJ, Torres J, Cascales P, Terol E, Castañer J, et al. Successful use of a single chest drain postlobectomy instead of two classical drains: a randomized study. Eur J Cardiothorac Surg. 2006 Apr;29(4):562–566. https://doi.org/10.1016/j.ejcts.2006.01.019

6. Pawelczyk K, Marciniak M, Kacprzak G, Kolodziej J. One or two drains after lobectomy? A comparison of both methods in the immediate postoperative period. Thorac Cardiovasc Surg. 2007 Aug;55(5):313–316. https://doi.org/10.1055/s-2007-964930

7. Okur E, Baysungur V, Tezel C, Sevilgen G, Ergene G, Gokce M, et al. Comparison of the single or double chest tube applications after pulmonary lobectomies. Eur J Cardiothorac Surg. 2009 Jan;35(1):32–35. https://doi.org/10.1016/j.ejcts.2008.09.009

8. Tanaka M, Sagawa M, Usuda K, Machida Y, Ueno M, Motono N, et al. Postoperative drainage with one chest tube is appropriate for pulmonary lobectomy: a randomized trial. Tohoku J Exp Med. 2014 Jan;232(1):55–61. https://doi.org/10.1620/tjem.232.55

9. Alex J, Ansari J, Bahalkar P, Agarwala S, Rehman MU, Saleh A, et al. Comparison of the immediate postoperative outcome of using the conventional two drains versus a single drain after lobectomy. Ann Thorac Surg. 2003 Oct;76(4):1046–1049. https://doi.org/10.1016/s0003-4975(03)00884-1

10. Zhou D, Deng XF, Liu QX, Chen Q, Min JX, Dai JG. Single chest tube drainage is superior to double chest tube drainage after lobectomy: a meta-analysis. J Cardiothorac Surg. 2016 May 27;11(1):88. https://doi.org/10.1186/s13019-016-0484-1

11. Zhang X, Lv D, Li M, Sun G, Liu C. The single chest tube versus double chest tube application after pulmonary lobectomy: A systematic review and meta-analysis. J Cancer Res Ther. 2016 Dec;12(Supplement):C309–C316. https://doi.org/10.4103/0973-1482.200743

12. French DG, Plourde M, Henteleff H, Mujoomdar A, Bethune D. Optimal management of postoperative parenchymal air leaks. J Thorac Dis. 2018 Nov;10(Suppl 32):S3789–S3798. https://doi.org/10.21037/jtd.2018.10.05

13. Cerfolio RJ. Advances in thoracostomy tube management. Surg Clin North Am. 2002 Aug;82(4):833–848. https://doi.org/10.1016/s0039-6109(02)00026-9

14. Gonfiotti A, Viggiano D, Voltolini L, Bertani A, Bertolaccini L, Crisci R, et al. Enhanced recovery after surgery and video-as- sisted thoracic surgery lobectomy: the Italian VATS Group surgical protocol. J Thorac Dis. 2018 Mar;10(Suppl 4):S564–S570. https://doi.org/10.21037/jtd.2018.01.157

15. Varela G, Jiménez MF, Novoa NM, Aranda JL. Postoperative chest tube management: measuring air leak using an electronic device decreases variability in the clinical practice. Eur J Cardiothorac Surg. 2009 Jan;35(1):28–31. https://doi.org/10.1016/j.ejcts.2008.09.005

16. Cerfolio RJ, Bryant AS. The benefits of continuous and digital air leak assessment after elective pulmonary resection: a pro- spective study. Ann Thorac Surg. 2008 Aug;86(2):396–401. https://doi.org/10.1016/j.athoracsur.2008.04.016

17. Brunelli A, Salati M, Refai M, Di Nunzio L, Xiumé F, Sabbatini A. Evaluation of a new chest tube removal protocol using digital air leak monitoring after lobectomy: a prospective randomised trial. Eur J Cardiothorac Surg. 2010 Jan;37(1):56–60. https://doi.org/10.1016/j.ejcts.2009.05.006

18. Filosso PL, Ruffini E, Solidoro P, Molinatti M, Bruna MC, Oliaro A. Digital air leak monitoring after lobectomy for primary lung cancer in patients with moderate COPD: can a fast-tracking algorithm reduce postoperative costs and complications? J Car- diovasc Surg (Torino). 2010 Jun;51(3):429–433.

19. Pompili C, Detterbeck F, Papagiannopoulos K, Sihoe A, Vachlas K, Maxfield MW, et al. Multicenter international randomized comparison of objective and subjective outcomes between electronic and traditional chest drainage systems. Ann Thorac Surg. 2014 Aug;98(2):490–496. https://doi.org/10.1016/j.athoracsur.2014.03.043

20. Bertolaccini L, Rizzardi G, Filice MJ, Terzi A. “Six sigma approach” - an objective strategy in digital assessment of postop- erative air leaks: a prospective randomised study. Eur J Cardiothorac Surg. 2011 May;39(5):e128–132. https://doi.org/10.1016/j.ejcts.2010.12.027

21. Cho HM, Hong YJ, Byun CS, Hwang JJ. The usefulness of Wi-Fi based digital chest drainage system in the post-operative care of pneumothorax. J Thorac Dis. 2016 Mar;8(3):396–402. https://doi.org/10.21037/jtd.2016.02.54

22. Lijkendijk M, Licht PB, Neckelmann K. Electronic versus traditional chest tube drainage following lobectomy: a randomized trial. Eur J Cardiothorac Surg. 2015 Dec;48(6):893–898. https://doi.org/10.1093/ejcts/ezu535

23. Plourde M, Jad A, Dorn P, Harris K, Mujoomdar A, Henteleff H, et al. Digital Air Leak Monitoring for Lung Resection Patients: A Randomized Controlled Clinical Trial. Ann Thorac Surg. 2018 Dec;106(6):1628–1632. https://doi.org/10.1016/j.athoracsur.2018.06.080

24. Chiappetta M, Lococo F, Nachira D, Ciavarella LP, Congedo MT, Porziella V, et al. Digital Devices Improve Chest Tube Man- agement: Results from a Prospective Randomized Trial. Thorac Cardiovasc Surg. 2018 Oct;66(7):595–602. https://doi.org/10.1055/s-0037-1607443

25. Coughlin SM, Emmerton-Coughlin HMA, Malthaner R. Management of chest tubes after pulmonary resection: a systematic review and meta-analysis. Can J Surg. 2012 Aug;55(4):264–270. https://doi.org/10.1503/cjs.001411

26. Zhou J, Chen N, Hai Y, Lyu M, Wang Z, Gao Y, et al. External suction versus simple water-seal on chest drainage following pulmonary surgery: an updated meta-analysis. Interact Cardiovasc Thorac Surg. 2019 Jan 1;28(1):29–36. https://doi.org/10.1093/icvts/ivy216

27. Chang PC, Chen KH, Jhou HJ, Lee CH, Chou SH, Chen PH, et al. Promising Effects of Digital Chest Tube Drainage System for Pulmonary Resection: A Systematic Review and Network Meta-Analysis. J Pers Med. 2022 Mar 22;12(4):512. https://doi.org/10.3390/jpm12040512

28. Brunelli A, Salati M, Pompili C, Refai M, Sabbatini A. Regulated tailored suction vs regulated seal: a prospective randomized trial on air leak duration. Eur J Cardiothorac Surg. 2013 May;43(5):899–904. https://doi.org/10.1093/ejcts/ezs518

29. Marjański T, Sternau A, Rzyman W. THORACIC SURGERY<br>The implementation of a digital chest drainage system signifi- cantly reduces complication rates after lobectomy – a randomized clinical trial. Kardiochirurgia i Torakochirurgia Polska/Polish Journal of Thoracic and Cardiovascular Surgery. 2013;10(2):133–138. https://doi.org/10.5114/kitp.2013.36133

30. Gocyk W, Kużdżał J, Włodarczyk J, Grochowski Z, Gil T, Warmus J, et al. Comparison of Suction Versus Nonsuction Drainage After Lung Resections: A Prospective Randomized Trial. Ann Thorac Surg. 2016 Oct;102(4):1119–1124. https://doi.org/10.1016/j.athoracsur.2016.04.066

31. Leo F, Duranti L, Girelli L, Furia S, Billè A, Garofalo G, et al. Does external pleural suction reduce prolonged air leak after lung resection? Results from the AirINTrial after 500 randomized cases. Ann Thorac Surg. 2013 Oct;96(4):1234–1239. https://doi.org/10.1016/j.athoracsur.2013.04.079

32. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, et al. Guidelines for enhanced recov- ery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019 Jan 1;55(1):91–115. https://doi.org/10.1093/ejcts/ezy301

33. Toth JW, Reed MF, Ventola LK. Chest Tube Drainage Devices. Semin Respir Crit Care Med. 2019 Jun;40(3):386–393. https://doi.org/10.1055/s-0039-1694769

34. French DG, Dilena M, LaPlante S, Shamji F, Sundaresan S, Villeneuve J, et al. Optimizing postoperative care protocols in tho- racic surgery: best evidence and new technology. J Thorac Dis. 2016 Feb;8(Suppl 1):S3–S11. https://doi.org/10.3978/j.issn.2072-1439.2015.10.67

35. Drahush N, Miller AD, Smith JS, Royer AM, Spiva M, Headrick JR. Standardized Approach to Prolonged Air Leak Reduction After Pulmonary Resection. Ann Thorac Surg. 2016 Jun;101(6):2097–2101. https://doi.org/10.1016/j.athoracsur.2016.01.049

36. Reeb J, Falcoz PE, Olland A, Massard G. Are daily routine chest radiographs necessary after pulmonary surgery in adult pa- tients? Interact Cardiovasc Thorac Surg. 2013 Dec;17(6):995–998. https://doi.org/10.1093/icvts/ivt352

37. Brunelli A, Beretta E, Cassivi SD, Cerfolio RJ, Detterbeck F, Kiefer T, et al. Consensus definitions to promote an evidence-based approach to management of the pleural space. A collaborative proposal by ESTS, AATS, STS, and GTSC. Eur J Cardiothorac Surg. 2011 Aug;40(2):291–297. https://doi.org/10.1016/j.ejcts.2011.05.020

38. Liberman M, Muzikansky A, Wright CD, Wain JC, Donahue DM, Allan JS, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg. 2010 Mar;89(3):891–897. https://doi.org/10.1016/j.athoracsur.2009.12.012

39. Jabłonski S, Kordiak J, Wcisło S, Terlecki A, Misiak P, Santorek-Strumiłło E, et al. Outcome of pleurodesis using different agents in management prolonged air leakage following lung resection. Clin Respir J. 2018 Jan;12(1):183–192. https://doi.org/10.1111/crj.12509

40. Rinaldi S, Felton T, Bentley A. Blood pleurodesis for the medical management of pneumothorax. Thorax. 2009 Mar;64(3):258– 260. https://doi.org/10.1136/thx.2007.089664

41. Dumire R, Crabbe MM, Mappin FG, Fontenelle LJ. Autologous “blood patch” pleurodesis for persistent pulmonary air leak. Chest. 1992 Jan;101(1):64–66. https://doi.org/10.1378/chest.101.1.64

42. Karampinis I, Galata C, Arani A, Grilli M, Hetjens S, Shackcloth M, et al. Autologous blood pleurodesis for the treatment of postoperative air leaks. A systematic review and meta-analysis. Thorac Cancer. 2021 Oct;12(20):2648–2654. https://doi.org/10.1111/1759-7714.14138

43. Andreetti C, Venuta F, Anile M, De Giacomo T, Diso D, Di Stasio M, et al. Pleurodesis with an autologous blood patch to pre- vent persistent air leaks after lobectomy. J Thorac Cardiovasc Surg. 2007 Mar;133(3):759–762. https://doi.org/10.1016/j.jtcvs.2006.10.042

44. Oliveira FHS, Cataneo DC, Ruiz RL, Cataneo AJM. Persistent pleuropulmonary air leak treated with autologous blood: results from a university hospital and review of literature. Respiration. 2010;79(4):302–306. https://doi.org/10.1159/000226277

45. Yokomise H, Satoh K, Ohno N, Tamura K. Autoblood plus OK432 pleurodesis with open drainage for persistent air leak after lobectomy. Ann Thorac Surg. 1998 Feb;65(2):563–565. https://doi.org/10.1016/s0003-4975(97)01309-x

46. Korasidis S, Andreetti C, D’Andrilli A, Ibrahim M, Ciccone A, Poggi C, et al. Management of residual pleural space and air leaks after major pulmonary resection. Interact Cardiovasc Thorac Surg. 2010 Jun;10(6):923–925. https://doi.org/10.1510/icvts.2009.231241

47. Droghetti A, Schiavini A, Muriana P, Comel A, De Donno G, Beccaria M, et al. Autologous blood patch in persistent air leaks after pulmonary resection. J Thorac Cardiovasc Surg. 2006 Sep;132(3):556–559. https://doi.org/10.1016/j.jtcvs.2006.05.033

48. Hasan IS, Allen MS, Cassivi SD, Harmsen WS, Mahajan N, Nichols FC, et al. Autologous blood patch pleurodesis for pro- longed postoperative air leaks. J Thorac Dis. 2021 Jun;13(6):3347–3358. https://doi.org/10.21037/jtd-20-1761

49. Dye K, Jacob S, Ali M, Orlando D, Thomas M. Autologous Blood Patching to Mitigate Persistent Air Leaks Following Pulmo- nary Resection: A Novel Approach. Cureus. 2020 Apr 20;12(4):e7742. https://doi.org/10.7759/cureus.7742

50. Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest. 2017 Aug;152(2):417–423. https://doi.org/10.1016/j.chest.2017.02.020

51. Mahajan AK, Doeing DC, Hogarth DK. Isolation of persistent air leaks and placement of intrabronchial valves. J Thorac Car- diovasc Surg. 2013 Mar;145(3):626–630. https://doi.org/10.1016/j.jtcvs.2012.12.003

52. Travaline JM, McKenna RJ, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest. 2009 Aug;136(2):355–360. https://doi.org/10.1378/chest.08-2389

53. Gillespie CT, Sterman DH, Cerfolio RJ, Nader D, Mulligan MS, Mularski RA, et al. Endobronchial valve treatment for prolonged air leaks of the lung: a case series. Ann Thorac Surg. 2011 Jan;91(1):270–273. https://doi.org/10.1016/j.athoracsur.2010.07.093

54. Reed MF, Gilbert CR, Taylor MD, Toth JW. Endobronchial Valves for Challenging Air Leaks. Ann Thorac Surg. 2015 Oct;100(4):1181–1186. https://doi.org/10.1016/j.athoracsur.2015.04.104

55. Mahajan AK, Khandhar SJ. Bronchoscopic valves for prolonged air leak: current status and technique. J Thorac Dis. 2017 Mar;9(Suppl 2):S110–S115. https://doi.org/10.21037/jtd.2016.12.63

56. Burt BM, Shrager JB. Prevention and management of postoperative air leaks. Ann Cardiothorac Surg. 2014 Mar;3(2):216– 218. https://doi.org/10.3978/j.issn.2225-319X.2014.03.03

57. Cerfolio RJ, Minnich DJ, Bryant AS. The removal of chest tubes despite an air leak or a pneumothorax. Ann Thorac Surg. 2009 Jun;87(6):1690–1694. https://doi.org/10.1016/j.athoracsur.2009.01.077

58. Royer AM, Smith JS, Miller A, Spiva M, Holcombe JM, Headrick JR. Safety of Outpatient Chest Tube Management of Air Leaks After Pulmonary Resection. Am Surg. 2015 Aug;81(8):760–763.

59. Schmocker RK, Vanness DJ, Macke RA, Akhter SA, Maloney JD, Blasberg JD. Outpatient air leak management after lobec- tomy: a CMS cost analysis. J Surg Res. 2016 Jun 15;203(2):390–397. https://doi.org/10.1016/j.jss.2016.03.043

60. Kit OI, Vodolazhsky DI, Maksimov AYu, Lazutin YuN, Pyltsin SP, Leyman IA, et al. Molecular genetic and phenotypic character- istics of patients with lung adenocarcinoma among inhabitants of the south of Russia. Molecular Medicine. 2016;14(6):35–40. (In Russ.). EDN: UYXTTA