From the Guidelines
An air leak in a chest tube indicates that air is escaping from the lungs or airways into the pleural space and then exiting through the chest tube system, which can prevent full lung re-expansion and prolong hospitalization. This commonly occurs after lung surgery, trauma, or in conditions like pneumothorax (collapsed lung) [ 1 ]. When observing a chest tube drainage system, an air leak appears as bubbling in the water seal chamber during exhalation. Air leaks are classified as continuous (present throughout the respiratory cycle) or intermittent (only during certain phases of breathing).
Some key points to consider in the management of air leaks include:
- Most small air leaks resolve spontaneously within a few days as the lung tissue heals [ 1 ].
- Management typically involves maintaining the chest tube until the leak seals, ensuring the drainage system functions properly, and monitoring for complications.
- Persistent air leaks (lasting more than 5-7 days) may require additional interventions such as pleurodesis (chemical sealing of the pleural space), blood patch procedures, or surgical repair [ 1 ].
- The British Thoracic Society guideline for pleural disease recommends considering video-assisted thoracoscopy access for surgical pleurodesis in the general management of pneumothorax in adults [ 1 ].
- Accepted indications for surgical advice include first pneumothorax presentation associated with tension, second ipsilateral pneumothorax, and persistent air leak (despite 5–7 days of chest tube drainage) or failure of lung re-expansion [ 1 ].
In terms of timing for thoracic surgical intervention, each case should be assessed individually on its own merit, with patient choice informing the decision, weighing the benefits of a reduced recurrence risk against that of chronic pain and paraesthesia [ 1 ]. Patients with pneumothoraces should be managed by a respiratory physician, and a thoracic surgical opinion will often form an early part of the management plan.
From the Research
Definition of Air Leak in Chest Tube
- An air leak in a chest tube refers to the presence of air escaping from the lung into the pleural cavity, which can occur after a pulmonary resection or other thoracic trauma 2, 3.
- This condition can be managed conservatively or through simple pleural aspiration or drainage, but in some cases, it may require more invasive techniques such as bronchoscopic sealing of air leaks 3.
Causes and Prevalence of Air Leaks
- Air leaks can occur in approximately 30-50% of patients immediately after pulmonary resection surgery 2.
- Prolonged air leaks (PALs) can predict an increased hospital length of stay, additional chest tube days, and increased pain 2.
- The presence of an air leak is currently a contraindication for removal of a chest tube, but some studies suggest that chest tubes can be safely removed even if the patient has a pneumothorax, if certain criteria are met 4.
Management of Air Leaks
- Digital and traditional chest drainage devices are used to manage air leaks after thoracic surgery 2.
- Treatment of air leaks can include lung protective ventilation, chemical pleurodesis, autologous blood patching, and bronchoscopic insertion of endobronchial valves 5.
- Some studies suggest that patients with air leaks can be safely discharged home with their chest tubes, and that these tubes can be safely removed even if the patient has a pneumothorax, if certain criteria are met 4, 6.
Complications and Outcomes
- Prolonged air leaks can lead to increased morbidity, health care expenditure, and resource utilization 5.
- Patients with air leaks may experience complications such as subcutaneous emphysema, pneumothorax, and empyema 4.
- However, some studies suggest that selective patients can be discharged home with a chest tube with reduced postoperative length of stay and without increase in major morbidity or mortality 6.