A Prospective Algorithm for the Management of Air Leaks After Pulmonary Resection

Transcription

1 A Prospective Algorithm for the Management of Air Leaks After Pulmonary Resection Robert J. Cerfolio, MD, Ramu P. Tummala, BS, William L. Holman, MD, George L. Zorn, MD, James K. Kirklin, MD, David C. McGiffin, MD, David C. Naftel, PhD, and Albert D. Pacifico, MD Division of Cardiothoracic Surgery, The University of Alabama at Birmingham, Birmingham, Alabama Background. Air leaks (ALs) are a common complication after pulmonary resection, yet there is no consensus on their management. Methods. An algorithm for the management of chest tubes (CT) and ALs was applied prospectively to 101 consecutive patients who underwent elective pulmonary resection. Air leaks were graded daily as forced expiratory only, expiratory only, inspiratory only, or continuous. All CTs were kept on 20 cm of suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H 2 O of suction. If a pneumothorax was present without an AL, the CT was returned to 20 cm H 2 O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry. Results. There were 101 patients (67 men); on postoperative day 1, 26 had ALs and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV 1 / FVC) (p 0.005), increased age (p 0.007), increased ratio of residual volume to total lung capacity (RV/TLC) (p 0.04), increased RV (p 0.02), and an increased functional residual capacity (FRC) (p 0.02) to predict the presence of an AL on postoperative day 1. By postoperative day 2, 22 patients had expiratory ALs. After 12 hours of water seal, 13 of the 22 patients ALs had stopped, and 3 more sealed by the morning of postoperative day 3. However, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Five of the 6 patients with ALs on postoperative day 4 still had ALs on postoperative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry. Conclusions. Most ALs after pulmonary resection are expiratory only. A low FEV 1 /FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Conversion from suction to water seal is an effective way of sealing expiratory AL, and pneumothorax is rare. If an expiratory AL does not stop by postoperative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment. (Ann Thorac Surg 1998;66: ) 1998 by The Society of Thoracic Surgeons Although air leaks are one of the most common problems after pulmonary resection, few studies have been performed on how they are best treated. We observed that large air leaks decrease significantly when chest tubes are taken off of suction and placed to water seal. Based on our experience with lung volume reduction surgery, we theorized that if the lung could remain expanded, air leaks may seal quicker with water seal than with suction. To test this hypothesis, a prospective randomized trial comparing the effects of suction with water seal on air leaks after pulmonary resection was planned. However, because there were no existing data showing the safety of water seal with air leaks in patients without emphysema, our institutional review board asked us to first show that water seal was safe. In response to their request, we developed an algorithm that was applied to the postoperative management of chest tubes. In this Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26 28, Address reprint requests to Dr Cerfolio, Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL protocol we placed chest tubes to water seal in the morning of postoperative day 2 in all patients. Patients and Methods Between July 1, 1996, and April 30, 1997, 101 consecutive patients underwent elective pulmonary resection by a single surgeon (R.J.C.) at The University of Alabama at Birmingham. Patients who had pulmonary resection performed by video thoracoscopy or thoracotomy were included in the trial. Any patient who had lung volume reduction surgery, pneumonectomy, or pulmonary resection with a bronchoplastic procedure or sleeve resection was excluded. All patients had the algorithm shown in Fig 1 applied to the management of their chest tubes. The clinical data of these 101 patients were gathered prospectively. Air leaks were classified daily by one observer (R.J.C.). A new classification system for air leaks was developed. An air leak was defined as forced expiratory only if it was present with cough, expiratory only if it was present during expiration, inspiratory only if it was present 1998 by The Society of Thoracic Surgeons /98/$19.00 Published by Elsevier Science Inc PII S (98)

2 Ann Thorac Surg CERFOLIO ET AL 1998;66: AIR LEAKS, WATER SEAL 1727 Fig 1. Algorithm used for chest tube (CT) management for air leak (A/L) based on chest roentgenograms (CXR). (POD postoperative day.) during inspiration, or continuous if the leak was present throughout the respiratory cycle. Pulmonary function testing was performed on all patients and was done on the 2450 Sensormedicus (Anaheim, CA) equipment. Arterial blood gases were also obtained. Patients who had adequate (for their planned procedure) pulmonary function testing performed at outside institutions did not have to repeat the testing, and their incomplete data were excluded from our statistical review. Operative technique included a double-lumen endotracheal tube and a posterolateral thoracotomy. Standard lung cancer operations were performed, except wedge resections were done in patients whose postoperative predicted diffusing capacity of the lung for carbon monoxide was less than 30% and either their postoperative predicted forced expiratory volume in 1 second (FEV 1 ) was less than 30%, their preoperative CO 2 was more than 48 mm Hg, or they had significant comorbidities. All staple lines were reinforced with the use of 4-0 Prolene (Ethicon, Somerville, NJ) on an small half needle. Warm sterile water was squirted over the lung to localize air leaks. Patients who underwent upper lobectomy had one anterior straight 28F chest tube placed in the apex and another placed posteriorly. Patients who underwent lower lobectomy had a straight 28F chest tube placed anteriorly in the apex and a 28F right-angle chest tube placed along the diaphragm. Chest roentgenograms were performed daily. All chest tubes were kept on 20 cm H 2 O of wall suction until the morning of postoperative day 2. They were then placed to water seal, and another chest roentgenogram was performed about 4 hours later. The algorithm was then followed as outlined in Fig 1. Chest tubes were removed when there was no air leak and the drainage was less then 250 ml day. Talc slurry was used for patients with air leaks after postoperative day 7. This technique dilutes 2.5 g of asbestos-free talc in 60 ml of sterile normal saline. The solution was vigorously shaken and mixed to prevent any small particles of talc from remaining out of solution and occluding the tube. The chest tube with the leak was disconnected from the drainage system and its end painted with soap. The talc solution was injected into the chest tube with a 60 ml catheter-tip syringe. The chest tube was then irrigated twice with 60 ml of sterile normal saline to prevent clogging. The tube was not clamped. Extension tubing was added to the chest tube and draped over a 6-foot-high intravenous pole, which prevents the talc from leaving the pleural space but allows air to be evacuated. Operative mortality was defined as any death that occurred during the hospitalization or within 30 days of operation. Late mortality was defined as any subsequent death. Follow-up data were obtained from clinic visits, by telephone interview, or from correspondence from other health care providers. All data are reported with medians and ranges. Univariable comparisons were made using 2 and Student s t tests. Multivariable analysis was performed using logistic regression. Results The median age at the time of pulmonary resection in these 101 patients (67 men and 34 women) was 60 years (range, 25 to 87 years). Sixty-three patients had preexisting conditions, which were a previous malignancy in 18, congestive heart failure in 18, hypertension in 16, diabetes in 10, liver transplantation in 3, heart transplantation in 2, and upper extremity fascitis with sepsis, lymphoma, human immunodeficiency virus, pregnancy, Wegener granulomatosis, and pericarditis in 1 each. Fifty-three patients presented with symptoms, which were shortness of breath in 32, fever in 11, cough in 10, chest pain in 5, hemoptysis in 5, and abdominal pain, weight loss, and malaise in 2 each. The indications for operation were a lung nodule or mass in 76 patients, tissue procurement for patients with interstitial lung disease in 12, empyema in 11, and an arteriovenous malformation and aspergilloma in 1 each. Sixty-nine patients had preoperative pulmonary function tests performed at our institution. These data are shown in Table 1. Types of pulmonary resection were lobectomy in 57 patients, wedge resection in 28 patients, and videoassisted wedge resection in 16 patients. On postoperative day 1, 26 patients had air leaks and 75 patients did not. All air leaks were expiratory only in all patients. On postoperative day 2, only 22 patients had expiratory air leaks. All chest tubes were then placed to water seal. Later that afternoon, after a minimum of 6 hours of water seal, only 9 patients had air leaks (leaks in 13 of 22 patients had stopped). No patient had a pneumothorax on the afternoon s chest x-ray film, which was checked a minimum of 4 hours after conversion to water seal. On the morning of postoperative day 3 only 6 patients had an air leak. However, 2 patients who had large leaks experienced small, apical pneumothoraces on the morning chest x-ray film of postoperative day 3. Both patients had their chest tubes placed, as stipulated by the protocol, to 10 cm H 2 O of wall suction, and a repeat chest roentgenogram was obtained. The pneumothorax resolved in 1, but the other patient required his chest tube to be placed to 20 cm H 2 O of wall suction and his lung reexpanded. (Both of these patients air leaks continued until postoperative day 7). On the morning of postoperative day 4, all

3 1728 CERFOLIO ET AL Ann Thorac Surg AIR LEAKS, WATER SEAL 1998;66: Table 1. Pulmonary Function Results for 69 University Patients PFT Variable Range Median ph Pco Po FVC FVC% FEV FEV 1 % MVV MVV% TLC TLC% RV RV% Dlco Dlco% FRC FRC% Dlco diffusing capacity of lung for carbon monoxide; FEV 1 forced expiratory volume in 1 second; FRC functional residual capacity; FVC forced vital capacity; MVV maximum voluntary ventilation; RV residual volume; TLC total lung capacity. 6 patients still had expiratory air leaks. By the morning of postoperative day 5 only 5 patients had an air leak. The characteristics of these patients are shown in Table 2. The 1 patient whose air leak stopped had been on water seal only since postoperative day 2. Of the 5 remaining patients, 3 were on water seal, 1 was on 10 cm H 2 O of wall suction, and the other was on 20 cm H 2 O of suction. All of these air leaks were expiratory only and all were large. All 5 patients underwent bedside talc slurry on postoperative day 7, and all leaks resolved by the morning of postoperative day 8. Univariable analysis showed a low FEV 1 to forced vital capacity ratio (p 0.005), increased age (p 0.007), increased residual volume to total lung capacity ratio (p 0.04), increased residual volume (p 0.02), and an increased functional residual capacity (p 0.02), to predict the presence of an air leak on postoperative day 1. Multivariable analysis showed a low FEV 1 to forced vital capacity ratio (p ), to be the best predictor of an air leak on postoperative day 1. Median hospital stay was 5 days (range, 3 to 55 days). There was no difference in the time it took to remove the chest tubes according to the type of procedure performed. Follow-up was complete in all patients (median, 6 months), and none have had a recurrent pneumothorax or empyema. Postoperative complications occurred in 14 patients and were a prolonged air leak in 5 patients, atrial fibrillation in 4, pneumonia in 2, and a superficial wound breakdown, a wound infection, and a pneumothorax after chest tube removal in 1 each. Three of the 5 patients who received talc slurry had a fever. Operative mortality was 3.0% (3 patients). One patient was critically ill from sepsis and had undergone an upper extremity fasciotomy for an ascending hand infection. We performed a decortication because of an empyema, which had failed chest tube drainage and urokinase treatment. He died on postoperative day 55 after being placed on do-notresucitate orders because of adult respiratory distress syndrome and multiorgan system failure. The second patient underwent a lobectomy for a T2 N2 M0 adenocarcinoma of the lung and had previously undergone radiation treatments for a stage I E lymphoma. He aspirated on postoperative day 4 and acquired pneumonia and adult respiratory distress syndrome and died on postoperative day 31. The third patient underwent a lobectomy for an unusual T4 N0 M0 atypical carcinoid (four separate nodules all in the right lower lobe). She had a massive pulmonary emboli on postoperative day 4 and died on postoperative day 7. Comment Formation of air leaks after pulmonary resection is an extremely common problem and can prolong hospitalization. Despite its frequency, there is little objective data on how air leaks should be treated. Most experts believe that wall suction is the best treatment [1 4]. New products are currently being developed to help treat air leaks in the operating room, but some of these are expensive and require special equipment (patches, glues, and sealants). Our goal was to develop a simple, inexpensive system available to all thoracic surgeons to help manage air leaks both in the operating room and postoperatively. We also wanted to develop a classification system that was reproducible, easy to learn, and could help guide treatment. We currently divide the problem of air leaks into four main categories: (1) preoperative risk factors for their development, (2) intraoperative techniques to prevent them, (3) immediate postoperative techniques to help seal them, and (4) the treatment of persistent ones. This Table 2. Characteristics of Patients With Air Leaks on Postoperative Day 5 Age Sex FEV 1 % Dlco% Paco 2 (mm Hg) Operation Type AL Talc Successful 62 F Wedge Expiratory Yes 54 M Wedge Expiratory Yes 47 F Wedge Expiratory Yes 62 M Lobectomy Expiratory Yes 62 M Wedge Expiratory Yes AL air leak; Dlco diffusing capacity of lung for carbon monoxide; FEV 1 forced expiratory volume in 1 second.

4 Ann Thorac Surg CERFOLIO ET AL 1998;66: AIR LEAKS, WATER SEAL 1729 trial statistically analyzed only the first and third category, but it should be stressed that the best way to treat air leaks is to prevent them. As one might expect we found age and some pulmonary function testing that is consistent with increased emphysema to be predictors of having an air leak the day after operation. We reinforced all staple lines with Prolene suture in this study to prevent possible staple line leaks. We also used pericardial strips (Biovascular, St Paul, MN) to reinforce the emphysematous lung, and most importantly, we carefully inspected the lung before closure to pinpoint air leaks and suture them. We do not believe that the normal stapled lung needs suture reinforcement but we did this to all staple lines for consistency in this study. The approach to air leaks should be systematic. First, one should ensure that the air leak is from the lung and not a system leak. Second, if the patient had a major bronchus that was closed (ie, a pneumonectomy, bilobectomy, lobectomy, or formal segmentectomy) and the leak is quite large and continuous, a bronchopleural fistula needs to be ruled out. We believe that peripheral air leaks are different and should really be called alveolarpleural fistulas and not bronchopleural fistulas, as the former rarely require reoperation but the latter usually do. In our experience, from patients not presented in this paper, air leaks from bronchopleural fistulas are usually continuous air leaks and are very large. They may be confirmed by bronchoscopy. Once a bronchopleural fistula is ruled out, then the leak can be called an alveolarpleural fistula, and it should be classified based on both its size and when it occurs in the respiratory cycle. We believe that both of these characteristics affect the rate and chance that an alveolar-pleural air leak may seal. Despite all preventive measures, air leaks after elective pulmonary resections, as seen in this series (26%), are frequent. They usually occur only during the expiratory phase of the respiratory cycle or with forced expiration (cough). Inspiratory air leaks are extremely unusual. During the period of this study, we treated several patients (not in this study) who transferred to our institution with inspiratory and continuous air leaks. All of these patients required intervention (such as talc slurry) to stop the leak. It appears that expiratory leaks may be more likely to seal without intervention than continuous or inspiratory leaks. We believe that the apposition of the parietal and visceral pleural is an important element for air leaks to seal. In this series, no patients had a pneumothorax before conversion to water seal, and this probably helped many air leaks seal. For this reason we are still using two chest tubes for lobectomy, especially in the patient who has small leaks that we cannot stop before chest closure with suture because of needle holes. Two patients did, however, experience a pneumothorax on postoperative day 3 after 24 hours of water seal. Both had significant air leaks. Because we believe that pleural pleural apposition is a crucial component for sealing, we developed our protocol to place these patients to 10 cm H 2 O of suction. Our reason for this inherent bias in the protocol was to minimize the amount of suction required, but maintain apposition. Both of these patients air leaks were smaller on 10 versus 20 cm H 2 O of suction. However, 1 patient continued to have a pneumothorax and required 20 cm H 2 O of suction. This did eliminate the pneumothoarx, but the air leak continued and actually increased on the higher suction. In all patients the size of the leak decreased immediately and dramatically when the chest tube was taken off suction. Water seal stopped the air leak in 60% of patients within 12 hours and in 73% of patients within 24 hours. The obvious criticism of this study is how do we know that all of these leaks would not have sealed if the patient had remained on suction, and how can we say that the size of the leaks decreased without an objective measurement? We believe that our ongoing prospective randomized trial will definitively answer the first criticism, and throughout this new trial we have been using an air leak meter that allows us to grade an air leak on a scale from 1 to 7. We now have objective measurements that document that air leaks do decrease with seal. As seen in this series, talc slurry is a highly effective way to stop expiratory air leaks that persist after 7 days. Other techniques for persistent air leaks have been tried [5 8]. Many surgeons are circumspect of talc in benign disease or in young patients, but reports have shown the safety of asbestos-free talc [9 17]. Because it seems to be the best and cheapest sclerotherapeutic agent for effusions we see no reason not to use it to achieve sclerotherapy for air leaks. We are not aware of any long-term complications with the use of 2.5 g asbestos-free talc. Although some are hesitant to use talc, there appears to be no data to support this view. We have, however, seen talc reaction, which consists of pleuritis, fever, and a hazy infiltrate of the lung. However the complication of severe pneumonitis and adult respiratory distress syndrome, which we observed on occasion using 7.5 or 10 g talc, has been eliminated using 2.5 g. In our series, if there was an air leak on postoperative day 4, there was a good chance (83%) that it would not seal by postoperative day 7. We now favor early (ie, postoperative day 5) talc pleurodesis in these patients. In conclusion, most air leaks after pulmonary resections are expiratory only. A low FEV 1 to forced vital capacity ratio, increased age, increased residual volume to total lung capacity ratio, increased residual volume, and an increased functional residual capacity were predictors of an air leak on postoperative day 1. Conversion from suction to water seal of chest tubes is a highly effective way of sealing expiratory air leaks. Pneumothorax is a rare complication from this technique. Talc slurry appears to be an effective treatment for persistent expiratory air leaks. References 1. Rice TW, Kirby TTJ. Prolonged air leak. Chest Surg Clin North Am 1992;2: Ponn RB, Silverman HJ, Federico JA. Outpatient chest tube management. Ann Thorac Surg 1997;64:

5 1730 CERFOLIO ET AL Ann Thorac Surg AIR LEAKS, WATER SEAL 1998;66: Paape K, Fry WA. Spontaneous pneumothorax. Chest Surg Clin North Am 1994;4: O Rourke JP, Yee ES. Civilian spontaneous pneumothorax: treatment options and long-term results. Chest 1989;96: LoCicero J III, Hartz RS, Frederikson JW, et al. New applications of laser in pulmonary surgery: hemostasis and sealing of airleaks. Ann Thorac Surg 1985;40: Matar AF, Hill JG, Duncan W, et al. Use of biological glue to control pulmonary air leaks. Thorax 1990;45: Turk R, Weidringer JW, Hartel W, et al. Closure of lung leaks by fibrin gluing. Experimental investigations and clinical experience. Thorac Cardiovasc Surg 1983;31: Kirschner PA. Provocative clamping and removal of chest tubes despite persistent air leak [Letter to the Editor]. Ann Thorac Surg 1992;53: Hausmann M, Keller R. Thoracoscopic pleurodesis in spontaneous pneumothorax. J Suisse Med 1994;124: Kennedy L, Vaughan LM, Steed LL, Sahn SA. Sterilization of talc for pleurodesis. Available techniques, efficacy, and cost analysis. Chest 1995;107: Viallat JR, Rey F, Astoul P, Boutin C. Thorascopic talc poudrage pleurodesis for malignant effusions. A review of 360 cases. Chest 1996;110: Weissberg D, Refaely Y. Pleural empyema: 24-year experience. Ann Thorac Surg 1996;62: Turler A, Walter M, Schmitz-Rixen T. Current treatment strategy in malignant pleural effusion. Wien Klin Wochensch 1996;108: Mouroux J, Perrin C, Venissac N, Blaive B, Richelme H. Management of pleural effusion of cirrhotic origin. Chest 1996;109: Schafers SJ, Dresler CM. Update on talc, bleomycin, and the tetracyclines in the treatment of malignant pleural effusions. Pharmacotherapy 1995;15: Colt HG, Dumon JF. Development of a disposable spray canister for talc pleurodesis. A preliminary report. Chest 1994;106: Hatta T, Tsubota N, Yoshimura M, et al. Intrapleural minocycline for postoperative air leakage and control of malignant pleural effusion. Jpn J Thorac Surg 1990;43: Viskum K, Lange P, Mortensen J. Long term sequelae after talc pleurodesis for spontantous pneumothorax. Pneumologie 1989;43: DISCUSSION DR JOSEPH I. MILLER, JR (Atlanta, GA): I would like to thank Dr Cerfolio for the opportunity to review his manuscript. I think he has carried out an important study to confirm concepts from 40 years ago and break out traditional thinking about chest tube suction. In the early years of thoracic surgery and during the TB era, generally no suction was utilized, and it was not until the late 1950s and 1960s that suction began to be applied. I myself grew up in the era of the two- or three-bottle system, and it was not until after I had gone into practice that Pleur-evacs were available. Again, it was Dr Joel Cooper who in the lung volume era suggested that we not utilize suction again in this specific type of patient; and if it was utilized, to not use greater than 10 cm. I would again like to ask three questions and offer one criticism. You have mentioned that the FEV 1 /FVC ratio was the best predictor of air leaks. What was your FEV 1 /FVC critical percent or number that you felt led to the intensity? This was not mentioned in your manuscript. You also comment in your manuscript that all staple lines were oversewn with running 4-0 Prolene, and I very rarely have found it necessary to oversew any staple line within the parenchyma, maybe in the lung volume group but certainly not in elective resections. You have already suggested that you are going now to a randomized trial going directly to water seal and I congratulate you on that. My only concern with your paper is the utilization of the talc slurry on day 7. And as now mentioned in the manuscript, you are doing it on day 5. Perhaps it is a lower dose of 2.5 g rather than the usual 5 g that causes fewer complications; however, I would urge caution in the utilization in this group of patients and I would also maybe consider sending them out with a Heimlich valve and you can get them out at the same period of time, plus the potential complications. I thank you. I think you have made an excellent presentation and I appreciate the opportunity to review the manuscript. DR CERFOLIO: Dr Miller, it is an honor to have you discussing the paper. You have three questions and I ll take them in order. (1) You would like a critical value of the FEV 1 ratio; I want the same thing from our statistician. Unfortunately, because this was done as a continuous variable he tells me it is not accurate to give a number to show above which or below which there is an actual predictor. So that is why that was not provided in the manuscript. Your second question was about oversewing the staple line with Prolene. I do not think you necessarily need to do this. I did that for this study just so there would be no questions about air leaks from staple lines. It was just done as a defensive way to have a nice regimen, uniform group of patients, but I completely concur that I do not think that it is a necessary thing to do. I do think, however, prior to closing the chest, one should spend 10 or 15 minutes in patients who have leaks really pinpointing the leak with an Asepto, squirting water over the lung, finding very small leaks and sewing them up. I think this is important. Your final criticism about talc is a very good point. I think there are a lot of people who are against talc and I think talc has a bad name because of previous experience. I think with the European long-term follow-up of talc now of 20 years and also with asbestos-free talc like we are using here in the States, I think that until we can really show that there are problems with it, I have found the 2.5 g to be very safe. As you know from the manuscript, I think there have been problems with 10 and even 5 g of talc. I think the data on talc for malignant effusions are that it works just as well as 2.5 at 5 and we may have less morbidity and, therefore, I am applying that to air leaks. We have generated an abstract on some patients with this and we are looking forward to presenting that one day. The final criticism I would have about a Heimlich valve is I think if I can send the patient home without a tube, with low morbidity by doing a talc, most patients, at least in Alabama, would prefer this. DR PAUL A. KIRSCHNER (New York, NY): I enjoyed this paper very much, but I find that there was no mention made of more prolonged air leaks after 7 days, ie, 7 to 10 days or longer. Our experience with that reveals that this group of patients have persisted with the air leak despite raising suction, lowering suction, water seal, and so on. We have developed a technique as follows; we call it provocative clamping [1]: In the presence of the air leak, we clamp the tubes, observe the patient with forced coughing and quiet breathing, and if there is no untoward effect, we do the same thing in the x-ray department, taking