What are the management guidelines for persistent air leak according to the British Thoracic Society (BTS), American Thoracic Society (ATS), and European Respiratory Society (ERS)?

Management of Persistent Air Leak According to BTS, ATS, and ERS Guidelines

Persistent air leak (PAL) should be referred to a respiratory physician after 48 hours of continued air bubbling through an intercostal tube, with surgical intervention considered after 5 days for primary spontaneous pneumothorax or earlier (3-5 days) for secondary spontaneous pneumothorax. 1

Definition and Initial Assessment

• PAL is defined as air leak continuing beyond 48-72 hours after chest tube placement 1
• Initial management includes:
  • Small-bore chest tube (10-14F) insertion using Seldinger technique 2
  • Connection to water seal device without initial suction 1
  • Supplemental oxygen to aid reabsorption 1

Referral Criteria

• Failure of pneumothorax to re-expand or persistent air leak exceeding 48 hours should prompt referral to a respiratory physician 2
• These patients require specialized management by physicians with specific training and established relationships with thoracic surgeons 2
• Chest drain management is best delivered by nurses with substantial experience in this area 2

Management Algorithm for Persistent Air Leak

1. After 48 Hours of Persistent Air Leak:

• Apply suction to intercostal tube if not already done 2
  • Use high volume, low pressure (-10 to -20 cm H₂O) suction systems 2
  • Manage only on lung units with specialist medical and nursing experience 2
• Consider chest drain repositioning if needed 2

2. Timing for Further Intervention:

• Primary spontaneous pneumothorax: Consider surgery after 5 days of persistent air leak 1
• Secondary spontaneous pneumothorax: Consider earlier intervention (3-5 days) due to:
  • Higher complication risks
  • Underlying lung disease
  • Large persistent air leak
  • Failure of lung re-expansion 1

3. Non-Surgical Management Options:

• Chemical pleurodesis for patients who are not surgical candidates 1
  • Preferred agents: talc or doxycycline
  • Can be performed through smaller tubes including indwelling catheter systems 2
• Autologous blood pleurodesis for patients not fit for surgery 1
• Endobronchial therapies (including valves) for poor surgical candidates 1

4. Surgical Options:

• Video-assisted thoracoscopic surgery (VATS) with staple bullectomy and pleural symphysis
  • Associated with shorter hospital stays and fewer complications 1
• Open thoracotomy and pleurectomy for difficult cases with lowest recurrence rate 1

Chest Tube Management Principles

• Avoid tube stripping or milking as it's ineffective and potentially harmful 1
• Never clamp a bubbling chest tube as it indicates an active air leak 1
• Remove chest tubes when:
  • Drainage is less than 100-150 mL per 24 hours (for pleural effusions/hemothorax)
  • No air leak is present
  • Lung is fully expanded on chest radiograph 1

Special Considerations

• Patients with underlying lung disease show slower resolution of air leaks:
  • 75% of air leaks in primary SP resolve by 7 days and 100% by 15 days
  • Only 61% of air leaks in secondary SP resolve by 7 days and 79% by 14 days 3
• Diabetic patients require more vigilant monitoring for glycemic control and may have atypical presentations 1
• Emphasize smoking cessation to reduce recurrence risk 1

Follow-Up Recommendations

• Arrange follow-up within 7-10 days after discharge 1
• Confirm complete resolution via chest radiograph before allowing air travel 1
• Advise permanent avoidance of scuba diving unless bilateral surgical pleurectomy has been performed 1

Common Pitfalls to Avoid

• Applying suction immediately after tube insertion (wait 48 hours) 2
• Using high pressure suction systems that can lead to air stealing, hypoxemia, or perpetuation of persistent air leaks 2
• Breaking sterile field to access inside of chest tubes, which increases infection risk 1
• Delaying referral to respiratory specialists beyond 48 hours for persistent air leaks 2