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Water seal chamber of a pleural drainage system. The higher the numbered column through which bubbling occurs, the larger the air leak.
Source publication
Persistent air leak (PAL) is a challenging clinical entity, particularly in the setting of critical illness. It is a significant cause of morbidity, health care expenditure, and resource utilization. Data on its prevalence in the critically ill patient population are limited. Unique patient factors often necessitate an individualized approach. Guid...
Contexts in source publication
Context 1
... air leak can be identified by the presence of bubbling in the water seal chamber of a collection system connected to a tube thoracostomy. Numbered columns in the water seal chamber can be used to assess the severity of an air leak (Figure 1). A larger leak is indicated by bubbling in a higher numbered column. ...
Context 2
... air leak can be identified by the presence of bubbling in the water seal chamber of a collection system connected to a tube thoracostomy. Numbered columns in the water seal chamber can be used to assess the severity of an air leak (Figure 1). A larger leak is indicated by bubbling in a higher numbered column. ...
Citations
... The clinical problem associated with intractable secondary pneumothorax (ISP) is that those patients are often not suitable for surgery because of ineffectual respiratory conditions due to the underlying disease [1]. Consequently, ISP without surgical indications poses a considerable challenge for respiratory physicians in clinical practice, given its poor prognosis and the absence of systematic treatment strategies [2]. ...
Background
The management of intractable secondary pneumothorax poses a considerable challenge as it is often not indicated for surgery owing to the presence of underlying disease and poor general condition. While endobronchial occlusion has been employed as a non-surgical treatment for intractable secondary pneumothorax, its effectiveness is limited by the difficulty of locating the bronchus leading to the fistula using conventional techniques. This report details a case treated with endobronchial occlusion where the combined use of transbronchoscopic oxygen insufflation and a digital chest drainage system enabled location of the bronchus responsible for a prolonged air leak, leading to the successful treatment of intractable secondary pneumothorax.
Case presentation
An 83-year-old male, previously diagnosed with chronic hypersensitivity pneumonitis and treated with long-term oxygen therapy and oral corticosteroid, was admitted due to a pneumothorax emergency. Owing to a prolonged air leak after thoracic drainage, the patient was deemed at risk of developing an intractable secondary pneumothorax. Due to his poor respiratory condition, endobronchial occlusion with silicone spigots was performed instead of surgery. The location of the bronchus leading to the fistula was unclear on CT imaging. When the bronchoscope was wedged into each subsegmental bronchus and low-flow oxygen was insufflated, a digital chest drainage system detected a significant increase of the air leak only in B5a and B5b, thus identifying the specific location of the bronchus leading to the fistula. With the occlusion of those bronchi using silicone spigots, the air leakage decreased from 200 mL/min to 20 mL/min, and the addition of an autologous blood patch enabled successful removal of the drainage tube.
Conclusion
The combination of transbronchoscopic oxygen insufflation with a digital chest drainage system can enhance the therapeutic efficacy of endobronchial occlusion by addressing the problems encountered in conventional techniques, where the ability to identify the leaking bronchus is dependent on factors such as the amount of escaping air and the location of the fistula.
... Chemical pleurodesis is frequently used in clinical settings to control air leaks, to stop a pneumothorax from recurring and to treat critical patients. 19 . ...
In cases of pneumothorax in the chest tube, the presence of air in the pleural cavity that lasts more than 5 to 7 days can be suspected as a persistent air leak (PAL), especially if an increased amount of air is obtained accompanied by the appearance of bubbles in the water seal drainage (WSD) system. This is the most common complication after surgery (8–26%), although it can be primary spontaneous pneumothorax (PSP) (26%) or secondary spontaneous pneumothorax (SSP) (39%). One condition that often causes difficulties in PAL therapy is infection due to direct contact with the fistula. The presence of PAL is associated with higher morbidity and mortality, prolonged chest tube inserted, and longer hospitalization. Observations of air production in PAL are expected to occur spontaneously within 4 days, if the leak persists, pleurodesis is recommended. If it was possible, surgery is needed to close the leak. Bronchoscopy treatment is only recommended in special circumstances where surgery is contraindicated or the patient refuses the surgical procedure.
... A persistent air leak (PAL) is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow [1]. The communication can originate from the subsegmental bronchus or a more distal portion of the airway, causing an alveolar-pleural fistula, or can originate from a segmental bronchus or a more proximal airway, causing a bronchopleural fistula [1]. ...
... A persistent air leak (PAL) is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow [1]. The communication can originate from the subsegmental bronchus or a more distal portion of the airway, causing an alveolar-pleural fistula, or can originate from a segmental bronchus or a more proximal airway, causing a bronchopleural fistula [1]. When the air leak persists beyond 5-7 days, it is classified as persistent or prolonged, leading to further risk of complications [2]. ...
... When the air leak persists beyond 5-7 days, it is classified as persistent or prolonged, leading to further risk of complications [2]. Several known risk factors for PAL have been previously described, including mechanical ventilation, thoracic trauma, pneumothorax, pulmonary surgery (such as lobectomy and lung volume reduction surgery), and pulmonary infection [1]. The SARS-CoV-2 virus, the causative organism of COVID-19 infection, has been a major cause of respiratory tract inflammation and subsequent pulmonary complications, including acute respiratory distress syndrome (ARDS) and pneumothorax, in recent years [3]. ...
An air leak is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow. The communication can originate from a distal portion of the airway, causing an alveolar-pleural fistula, or from a more proximal airway, causing a bronchopleural fistula. When the air leak persists beyond 5–7 days, it is classified as persistent air leak (PAL). PAL has serious implications on patient management and outcomes, such as prolonged chest tube maintenance, high rate of infections, ventilation-perfusion mismatch, and prolonged hospital stay with higher morbidity and mortality. There are currently no guidelines for the management of PAL in COVID-19 patients. We presented a case of PAL in a patient with COVID-19-associated pneumothorax successfully treated with a one-way endobronchial valve. We also reviewed current published cases of PAL secondary to COVID-19-associated pneumothorax and the various methods they were treated. The first line treatment was insertion of one or more chest tubes, but the persistence of an air leak then led to other treatment modalities. Initial early surgical evaluation followed by pleurodesis is recommended for the management of PAL. The most common surgical approaches include VATS or open thoracotomy with mechanical or chemical pleurodesis or pleurectomy. However, surgery is not always a feasible option for critically ill patients. In such cases, there are multiple less invasive options for the management of PAL, including implantable devices, such as Watanabe spigots and stents, and chemical agents, such as thermal treatments, hemostatic substances, and tissue adhesives.
... Air leaks, and particularly persistent air leaks, represent a challenging scenario in clinical practice. Unique circumstances in each case often necessitate an individualized approach based on patient and clinical factors [27]. Moreover, in critically ill patients, air leaks have to be addressed in the context of the patient's overall condition [28], with concurrent infection and ARDS often complicating an already challenging clinical scenario [27]. ...
... Unique circumstances in each case often necessitate an individualized approach based on patient and clinical factors [27]. Moreover, in critically ill patients, air leaks have to be addressed in the context of the patient's overall condition [28], with concurrent infection and ARDS often complicating an already challenging clinical scenario [27]. ...
... Therapeutic management of air leaks in critically ill patients should start with the ventilator. Lung ultraprotective ventilatory strategies that limit airways pressures might be the treatment of choice in those patients, as they reduce the risk of further developing air leaks and favor its resolution once one has occurred [27]. According to Grotberg et al. [28], in the event of an air leak, both inspiratory pressure and PEEP need to be minimized. ...
Extracorporeal CO2 removal (ECCO2R) is a therapeutic approach that allows protective ventilation in acute respiratory failure by preventing hypercapnia and subsequent acidosis. The main indications for ECCO2R in acute respiratory failure are COPD (chronic obstructive pulmonary disease) exacerbation, acute respiratory distress syndrome (ARDS) and other situations of asthmatics status. However, CO2 removal procedure is not extended to those ARDS patients presenting an air leak. Here, we report three cases of air leaks in patients with an ARDS that were successfully treated using a new ECCO2R device. Case 1 is a polytrauma patient that developed pneumothorax during the hospital stay, case 2 is a patient with a post-surgical bronchial fistula after an Ivor–Lewis esophagectomy, and case 3 is a COVID-19 patient who developed a spontaneous pneumothorax after being hospitalized for a prolonged time. ECCO2R allowed for protective ventilation mitigating VILI (ventilation-induced lung injury) and significantly improved hypercapnia and respiratory acidemia, allowing time for the native lung to heal. Although further investigation is needed, our observations seem to suggest that CO2 removal can be a safe and effective procedure in patients connected to mechanical ventilation with ARDS-associated air leaks.
... The fourth type of leak is found only during forced expiration (FE) or coughing and is known as a forced expiration air leak. However, this system of classification is generally better suited to patients who have undergone thoracic surgery and is not generally applicable to patients who are critically ill [25]. The decision regarding treatment in such patients is usually based on the clinical condition of the patient. ...
Persistent air leaks (PALs) are associated with prolonged hospital stays, contamination and sustained infection of the pleural space, and significant morbidity. A fistulous tract between the alveoli and the pleural space is referred to as an alveolar-pleural fistula (APF), whereas a fistulous tract between the bronchiole and the pleural space is referred to as a bronchopleural fistula (BPF). There is no consensus on the treatment, and multiple modalities exist for the management of persistent air leak (PAL). Autologous blood patch (ABP) is a relatively safe and inexpensive method that has been used for many years for the treatment of PALs.
We conducted an electronic database search between 08/24/2022 and 08/27/2022 in PubMed, Embase, and Cochrane using keywords. The following keywords were used: "Blood patch" OR "Autologous blood patch" AND "pleurodesis." Our study included all original studies with the prime focus on the etiology of PALs, clinical characteristics, procedural details of ABP, and outcomes of the proposed treatment. The primary outcomes that were the focus of our study were the time to seal the air leak, the time to remove the chest tube after air leak cessation, and the time to discharge from the hospital. To determine the safety of ABP, we also evaluated the procedural outcomes.
Our findings suggest a statistically significant decrease in the time to air leak cessation when compared to the control group (mean difference of -3.75 {95% CI: -5.65 to -1.85; P=0.001}) with considerable heterogeneity of I2=85% and P=0.001. However, the difference was not statistically significant when a lower dose of ABP (50 mL) was compared to a higher dose (100 mL) (mean difference of 1.48 {95% CI: -0.07 to 3.02; P=0.06}) and considerable heterogeneity of I2=80% and P=0.03. There was no statistically significant difference in the time to discharge when compared to the control group (mean difference of -2.12 {95% CI: -4.83 to 0.59; P=0.13}) and considerable heterogeneity (I2=95% and P<0.001).
When compared to the control group, ABP did not provide any statistically significant difference in the risk ratio for infection (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I2=33% and P=0.20}), pain (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I2=33% and P=0.20}), and fever (0.54 {95% CI: 0.27 to 1.10; P=0.09} and no heterogeneity {I2=0% and P=0.50}).
Our study concludes that using ABP caused a statistically significant decrease in the time to air leak cessation when compared to the control group. However, the procedure does not provide a statistically significant difference in the time to discharge from the hospital when compared to conservative treatment. Similarly, there was no statistically significant difference in the risk ratio for complications such as infection, pain, and fever when compared to conservative management. More studies need to be conducted to fully understand the efficacy and safety of ABP in the management of PALs.
... Using 100 mL of blood may be more effective than 50 mL (12). The blood may immediately patch the alveolar pleural fistula, and also induce inflammation and pleurodesis (15). The procedure is overall safe with only a few, rare complications, including chest tube obstruction, pleuritis, and empyema (2). ...
... 1,2 Recent consensus for management of PALs includes chemical pleurodesis, one-way endobronchial valves, and ABPP. 1,3,4 PALs are sometimes difficult to manage in the critical care setting, where patients may not tolerate invasive procedures. 4 ABPP typically involves injecting 50 to 100 mL of the patient's own blood within the pleural cavity through an existing chest tube. ...
... 1,3,4 PALs are sometimes difficult to manage in the critical care setting, where patients may not tolerate invasive procedures. 4 ABPP typically involves injecting 50 to 100 mL of the patient's own blood within the pleural cavity through an existing chest tube. 1,4,5 Patients are then placed in several different positions to allow homogeneous spread and the chest tube is usually removed within 12 hours after being placed on water seal. ...
... 4 ABPP typically involves injecting 50 to 100 mL of the patient's own blood within the pleural cavity through an existing chest tube. 1,4,5 Patients are then placed in several different positions to allow homogeneous spread and the chest tube is usually removed within 12 hours after being placed on water seal. 5 For blood patch pleurodesis to successfully seal an alveolar-pleural leak, complete lung re-expansion with pleural surfaces in contact must be maintained, along with necessity of sterile pleural fluid to avoid infection or empyema. ...
Autologous blood-patch pleurodesis (ABPP) is a common technique used to manage patients with persistent pleural air leaks caused by pneumothorax. Other treatment options for persistent air leak (PAL) include chemical pleurodesis or placement of endobronchial valves, though severity of illness, risk of complications such as infection, or patient comorbidities may impact treatment decisions. The use of ABPP in patients with HIV and AIDS has not been reported in the literature. We present a case of a 32-year-old man with a history of AIDS (noncompliant with medications) and schizophrenia who presented with acute hypoxemic respiratory failure complicated by pneumothorax and PAL. He safely underwent ABPP without complications and eventually had resolution of PAL.
... This can also result from bronchopleural fistula (BPF), where and abnormal connection between the airways and the pleural cavity. If this connection persists, there will be flow of air from the lung parenchyma to the pleural space and worsening of the pneumothorax (1). The conventional treatment by intercostal drainage can resolve a majority of pneumothorax and air leak. ...
... Occasionally, bacterial or fungus infections and tuberculosis could develop PAL. 1 Usually, PAL are relatively small in volume. Whether the leak is not diminishing or lasts several days for a week or more, chest drainage systems are instituted. ...
... An AL is referred to as a PAL when it persists longer than 5-7 d. This typically used 5-d cut-off to define PAL was initially derived from the expected length of stay following pulmonary resection, where an AL for several days was not uncommon [31,32]. However, some authors suggest that an AL in the setting of secondary spontaneous pneumothorax should be considered [31]. ...
... This typically used 5-d cut-off to define PAL was initially derived from the expected length of stay following pulmonary resection, where an AL for several days was not uncommon [31,32]. However, some authors suggest that an AL in the setting of secondary spontaneous pneumothorax should be considered [31]. Although the exact incidence of PAL is unknown, it may be prevalent in patients with COVID-19. ...
... There are reports of 80% of cases having been treated conservatively for 14 d with success; however, a delay in surgery may detrimentally affect surgical outcomes and prolong hospital stay. Therefore, an individualized approach to PAL is suggested to improve patient outcomes [31]. As per the two guidelines on the management of PAL, based on the consensus of expert panels, one should consider early surgery in case that the AL persists beyond 4 d, followed by pleurodesis to prevent recurrence [36,37]. ...
Coronavirus disease 2019 (COVID-19) continues to create havoc and may present with myriad complications involving many organ systems. However, the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected. There is a high incidence of air leaks in patients with COVID-19, leading to acute worsening of clinical condition. The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and un-derlying lung disease. The exact pathophysiology of air leaks with COVID-19 remains unclear, but multiple factors may play a role in their development. A significant proportion of air leaks may be asymptomatic; hence, a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality. These air leaks may even develop weeks to months after the disease onset, leading to acute deterioration in the post-COVID period. Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.
