From the Guidelines
An air leak after chest tube placement for a large iatrogenic pneumothorax is not uncommon and can be considered normal in the initial stages.
Key Considerations
- The presence of an air leak does not necessarily indicate a complication, but rather a potential delay in the resolution of the pneumothorax 1.
- The British Thoracic Society guidelines suggest that most spontaneous pneumothoraces will resolve once the air leak has ceased, but some patients may have persistent or prolonged air leaks 1.
- The management of patients with ongoing air leaks includes various treatment options, such as application of thoracic suction, conversion to larger-bore chest drain, blood patch, or chemical pleurodesis, endobronchial valves, or thoracic surgery 1.
Management of Air Leaks
- Suction should not be applied directly after tube insertion, but can be added after 48 hours for persistent air leak or failure of the pneumothorax to re-expand 1.
- High volume, low pressure (–10 to –20 cm H2O) suction systems are recommended for patients requiring suction 1.
- The decision to apply suction should be made on a case-by-case basis, taking into account the patient's underlying lung disease, size of the pneumothorax, and clinical stability 1.
Clinical Implications
- Patients with large iatrogenic pneumothoraces should be closely monitored for signs of persistent air leaks or failure of lung re-expansion, and managed accordingly 1.
- Early referral to a thoracic surgeon may be considered for patients with persistent air leaks or failure of lung re-expansion, particularly those with underlying lung disease 1.
From the Research
Air Leak After Chest Tube Placement
- An air leak after chest tube placement for a large iatrogenic pneumothorax can be a normal occurrence, especially in patients with underlying lung disorders 2.
- Studies have shown that in patients without underlying lung disease, gas egress typically stops within 72 hours after chest tube insertion 2.
- However, in patients with underlying lung disease, gas egress may persist for up to 10 days or more, and the use of more invasive approaches may be justified if the air leak persists 2, 3.
- The management of chest tubes in patients with a pneumothorax and an air leak is crucial, and placing chest tubes to water seal may be superior for patients with an air leak 4.
- Risk factors that predict failure of water seal include a large air leak and a pneumothorax greater than 8 cm in size 4.
- In some cases, persistent air leaks may be due to chest drain malposition, and awareness of this cause is essential for proper treatment 5.
- The use of endobronchial valves and digital drainage systems may be effective in treating persistent air leaks 3.
- Outpatient treatment of iatrogenic pneumothorax with short-term placement of a small-caliber chest tube may be feasible, and a 1-hour clamping trial can help identify patients with persistent air leaks 6.