From the Guidelines
Prolonged air leak is generally defined as an air leak that persists beyond 5-7 days after thoracic surgery or spontaneous pneumothorax, with the British Thoracic Society often using a 7-day threshold 1. The definition of prolonged air leak (PAL) varies across different thoracic societies, reflecting differences in clinical practices and patient populations.
- The American Association for Thoracic Surgery and European Society of Thoracic Surgeons typically define PAL as an air leak persisting beyond 5 days after surgery.
- The British Thoracic Society often uses a 7-day threshold, while some Asian thoracic societies may use criteria ranging from 3-7 days. The physiological basis for these timeframes relates to the normal healing process of lung tissue, which typically seals minor air leaks within 3-5 days. Management of PAL generally includes chest tube management with consideration for Heimlich valve conversion, blood patch pleurodesis using 50-100ml of autologous blood if conservative management fails after 7 days, and surgical intervention if the leak persists beyond 14 days, as recommended by the British Thoracic Society guidelines 1. These timeframe differences impact clinical decision-making, research comparability, and hospital length-of-stay metrics across different healthcare systems. It is essential to consider the individual patient's condition and the underlying cause of the air leak when determining the best course of management, as emphasized in the British Thoracic Society guidelines 1. The guidelines suggest that 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, with patient choice informing the decision, weighing the benefits of a reduced recurrence risk against that of chronic pain and paraesthesia 1.
From the Research
Definition of Prolonged Air Leak
- Prolonged air leak is defined as an air leak lasting more than 7 days after surgery, as stated in studies 2, 3, and 4.
- In study 5, a persistent air leak is defined as an air leak lasting more than 2 days.
Variations in Definition
- Different studies and societies may have varying definitions of prolonged air leak, with some considering it as an air leak lasting more than 2 days 5 and others as more than 7 days 2, 3, and 4.
- The definition of prolonged air leak may depend on the context, such as the type of surgery or the patient's underlying condition.
Factors Influencing Prolonged Air Leak
- Preoperative factors such as male gender, smoking history, low body mass index (BMI), and diffusion capacity for carbon monoxide below 80% (Dlco) may increase the risk of prolonged air leak, as reported in study 2.
- Intraoperative factors like lob- and bilobectomies, pleural adhesions, and length of stapler line may also contribute to the risk of prolonged air leak, as identified in study 4.
- Postoperative factors such as the use of active drainage, presence of subcutaneous emphysema, massive air leak on the first postoperative day, and incomplete re-expansion of the lung may also influence the development of prolonged air leak, as stated in study 4.
Management of Prolonged Air Leak
- Treatment options for prolonged air leak include supportive care, fibrin sealants, ethanol injection, metal coils, Watanabe spigots, chemical pleurodesis, autologous blood patch pleurodesis, and endobronchial valves, as described in study 6.
- Bronchoscopic sealing of air leaks can often avoid the requirement for thoracic surgical intervention, as reported in study 5.