Prolonged Air Leak After Lung Resection

Transcription

1 280 Current Respiratory Medicine Reviews, 2012, 8, Prolonged Air Leak After Lung Resection Ben M. Hunt and Ralph W. Aye * Swedish Cancer Institute and Medical Center, Seattle, WA 98104, USA Abstract: Prolonged air leak (PAL) is one of the most common complications after pulmonary resection. PAL is associated with longer hospital stay, increased morbidity, and increased cost. PAL can be defined in various ways, but the most commonly accepted definition is an air leak which prolongs the hospital stay. Patients with decreased lung function and emphysema are at the highest risk for PAL, as are patients with intrapleural adhesions. PAL is also associated with various risk factors for poor wound healing (e.g. steroids and malnutrition). PAL is more common after lobectomy, especially upper lobectomy. Fissureless techniques and VATS surgery have been associated with a decreased risk of PAL, as have buttressed staple lines, chemical sealants, and various measures to reduce the volume of the pleural cavity (such as creation of an apical tent or iatrogenic pneumoperitoneum). These techniques may be used routinely, but are usually employed only in high-risk patients or patients with an intraoperative air leak. Early use of water seal has been consistently demonstrated to reduce the incidence of PAL, except when a patient develops an expanding pneumothorax or worsening symptoms on water seal. Patients with PAL who tolerate water seal drainage can be discharged with a chest tube still in place attached to a one-way valve or portable drainage system. For recalcitrant PAL, sclerosants and endobronchial valves have both shown some success. Reoperation is required for <2% of patients with PAL. Keywords: Chest tube management, complications, lung resection, morbidity, prolonged air leak, persistent air leak, thoracic surgery. INTRODUCTION Persistent or prolonged air leak (PAL) can be a vexing problem after lung surgery. PAL is quite common, with a reported incidence from 4-16% [1-3]. PAL is associated with increased morbidity [4], longer hospital stay [5, 6], and increased expense [7]. Many studies identify PAL as the most frequent complication after lung resection [8-13]. This report will discuss the definition and epidemiology of PAL, and the strategies which have been devised for the prevention and management of air leaks. DEFINITION Air leaks after lung surgery result from the passage of air from the bronchial tree into the pleural space. A distinction should be made between an alveolopleural fistula, which arises from a leak distal to the segmental bronchus, and a bronchopleural fistula (BPF), which arises from a segmental bronchus or more proximal airway [14]. Most air leaks after lung surgery are alveolopleural fistulae [15, 16]. BPFs have different risk factors and often require surgical reintervention. BPFs are beyond the scope of this review. Various definitions of prolonged air leaks have been advocated. Initially, PAL was defined as an air leak lasting >7 days [17, 18]. More recently, authors have defined a PAL as one which prolongs the hospital stay [15] or requires reintervention [19]. Since the median hospital stay after pulmonary resection for lung cancer is 5 days [16], PAL has been defined as an air leak lasting >5 days [7, 11, 16], although there is still a fair amount of heterogeneity in the literature [20, 21] and some authors continue to use 7 days *Address correspondence to this author at the Swedish Cancer Institute, 1101 Madison St, Seattle, WA 98104, USA; Tel: (206) ; Fax: (206) ; ralph.aye@swedish.org (or longer) as the cutoff [10, 22, 23]. We favor the definition of a PAL as an air leak which prolongs the hospital stay. In the Ottawa Thoracic Morbidity and Mortality classification system, most PALs are Grade II, requiring pharmacologic treatment or minor intervention only [8]. Various methods have been used to quantify an air leak. Most simply, air leaks can be classified into continuous leaks, leaks that only occur during a particular phase of the respiratory cycle, and leaks that occur after a provoking event: cough, valsalva, or deep breathing [24]. The water seal chambers in many commercially available chest tube drainage systems have multiple inflow ports, so an air leak may be graded more quantitatively by how many of the ports bubble at once [1]. Several digital chest tube drainage systems are also commercially available, e.g. Thopaz, (Medela, Baar, Switzerland) and Atmos (Atmos, Allentown, Pennsylvania, USA). They incorporate a portable suction pump that records flow and logs the data over time. These systems allow precise quantification of an air leak coupled with the ability to trend the air leak over time, which can help to document an intermittent air leak. CONSEQUENCES OF PROLONGED AIR LEAK PAL has been associated with a variety of adverse consequences. Hospital stay is significantly prolonged in patients with PAL [5-7, 12, 15, 21, 25, 26]. PAL was estimated to increase the cost of a hospital stay by approximately EUR 1900 per patient (USD 1900, using the exchange rate at the time the data were collected), in large part due to extended length of stay [7]. Strategies for outpatient chest tube management may mitigate the effect of PAL on hospital stay in selected patients [27]. PAL has been associated with an increased incidence of empyema [6, 7, 25], which may be caused by recurrent /12 $ Bentham Science Publishers

2 Prolonged Air Leak Current Respiratory Medicine Reviews, 2012, Vol. 8, No contamination of the pleural space with organisms from the tracheobronchial tree. Failure to eradicate the pleural space and persistence of dead space between the visceral and parietal pleura may contribute to increased risk for empyema as well. PAL has also been associated with cardiac complications [4], pneumonia [23], and readmission to the ICU [23]. Postoperative chemotherapy is indicated after many lung resections, whether they are for primary lung cancer or for metastasectomy [28]. Prolonged thoracostomy tube drainage of the pleural space can delay chemotherapy or predispose to infectious complications which interrupt chemotherapy [29]. PATIENT RISK FACTORS There are two categories of risk factors for air leak after lung surgery: patient risk factors and technical risk factors. The most commonly identified patient risk factor for PAL is preoperative or predicted postoperative impaired lung function [1, 2, 6, 9, 11, 12, 15, 21, 24, 26, 30-32]. Patients with significant emphysema are at an increased risk for PAL [1, 12, 32, 33], and meticulous care must be taken during surgery to minimize this risk [12, 15]. The destruction of connective tissue which is associated with emphysema and the increased compliance of emphysematous lungs which may lead to overexpansion [34] can cause lungs to rip adjacent to staple lines [6] and delay healing after surgery [4]. Redistribution of tension from staple lines also been hypothesized to cause tears in the visceral pleura in areas far from the actual staple lines [35], which is an event we have observed in our own practice. Increased backpressure from the increased airway resistance in chronic obstructive pulmonary disease can be another factor predisposing to PAL in patients with decreased lung function [23, 26]. Postoperative air leaks are also more likely if a patient has extensive intrapleural adhesions and adhesiolysis or decortication is required [23, 26, 30, 31]. Incomplete or fused fissures have also been associated with an increased risk of PAL [36]. A higher rate of PAL has also been reported after lobectomy compared to wedge resection [1, 6, 30], and particularly after upper lobectomy [2, 30]. This may be related to poor visceral/parietal pleural apposition after lobectomy versus wedge resection and upper lobectomy versus other lobectomies [12]. A higher rate of PAL has been independently associated with a pneumothorax on postoperative chest x-ray [15, 21]. For unclear reasons, male gender [1, 15, 23, 30, 32] and Caucasian race [23] have also been associated with increased risk of PAL, independent of the severity of emphysema. Factors which interfere with robust healing have also been associated with an increased risk of PAL; examples are steroid use [1, 23], malnutrition [10, 30], diabetes mellitus [10], and age [11, 32]. Infection is a risk factor for poor wound healing, and an association between empyema and PAL has been reported [6, 25], as mentioned above. However, if there is an association between PAL and empyema, PAL may be the causative factor rather than the result. Patients who require positive pressure ventilation postoperatively have been excluded from several studies [2], and the requirement for mechanical ventilation has not been part of the predictive model in other studies [1, 21], so it is difficult to say whether mechanical ventilation postoperatively is associated with increased incidence of PAL. Two clinical scoring systems have been recently developed to predict which patients are most likely to have PAL [30, 37]. Both scoring systems include the presence of adhesions and decreased lung function, and one includes male gender, extent of resection, and BMI as a proxy for nutritional status [30]. Predicting which patients will have PAL allows surgeons to employ intraoperative strategies to minimize the chance of PAL in high-risk patients. TECHNICAL FACTORS Various techniques may be employed to decrease the frequency of PAL. One of the basic tenets of safe thoracic surgery is meticulous attention to dissecting along anatomic planes, attempting to preserve the integrity of the visceral pleura whenever possible [15]. When it is necessary to transect the lung parenchyma, staplers are commonly used [38, 39]. Avoiding dissection in the fissures whenever possible, dividing hilar structures first, and completing fissures with stapling devices when necessary (the fissureless lobectomy ) has been associated with decreased incidence of PAL in both retrospective [40] and randomized [36] series. VATS lobectomy has been associated with a lower incidence of PAL when compared with open lobectomy [41]. Various authors have examined the effect of buttressing the staple line with a sheet of material, in an attempt to distribute the forces of lung reexpansion along a larger area of visceral pleura [42, 43]. Buttressing the staple line might also prevent leaks at puncture sites from individual staples [42]. However, buttressing strips add cost to surgery, and have been associated with complications such as fibrosis, inflammation, and erosion. There have been reports of expectoration of staples and even of the entire strips [34, 44]. Multiple randomized trials have evaluated staples with and without various buttressing materials for transection of lung parenchyma during lung volume reduction surgery (LVRS) for emphysema, and have shown consistent benefit in terms of reducing PAL and length of stay [45]. One large exception, the National Emphysema Treatment Trial, did not find a significant effect of buttressing or type of buttress on PAL [23], but the trial was not designed to test the effect of buttressing: only 5% of the patients had resection without buttressing, and patients were not randomized to buttressed or unbuttressed stapling. Buttressed staple lines are almost uniformly used in LVRS [23]. However, whether the data in favor of buttressing staple lines in LVRS can be generalized to draw conclusions about transecting emphysematous or even healthy lung outside the setting of LVRS (e.g. wedge resection or completing fissures during lobectomy) is debatable [45, 46]. A few randomized trials have compared buttressed versus unbuttressed staple lines in series of unselected patients outside the setting of LVRS, and results have been equivocal [47, 48]. Taking account of the evidence supporting buttressed staple lines in LVRS, together with the conflicting data in unselected patients, our current practice is to use buttressed staple lines in particularly fragile lungs, or to re-staple areas where existing staple lines have persistent leaks, but not to use buttressed staplers in every patient.

3 282 Current Respiratory Medicine Reviews, 2012, Vol. 8, No. 4 Hunt and Aye Various sealants and glues have also been proposed to assist with pneumostasis during lung resection, and they are the subject of a recent Cochrane review [49]. Almost uniformly, the studies which have been selected for publication show a decrease in intraoperative air leak after application of sealant. However, a more relevant question is whether sealants decrease PAL, hospital stay, or long-term morbidity or mortality. Data from the published trials are much more equivocal regarding these clinical outcomes. Most of the studies of sealants use them on all patients indiscriminately or all patients with intraoperative air leak, regardless of the postoperative risk of PAL. Future studies could focus on those patients at highest risk for PAL, using the known risk factors which have been enumerated here or one of the formalized risk scores for PAL [30, 37]. Until consistent benefit in particular high-risk groups has been shown, we (and others) do not recommend the routine use of sealants after lung resection, although they certainly may be considered on a case-by-case basis in high-risk situations [30, 45, 49]. At the completion of the resection, it is important to reinflate the remaining lung under direct vision to determine whether an air leak is apparent upon reinflation. If an air leak is present, the site of the leak must be identified and addressed. Reinforcement of existing staple lines or bronchial closures with simple or pledgeted suture, restapling (perhaps with buttressed staplers), application of sealants, and electrocautery may be used to assure intraoperative pneumostasis. After ensuring that all large air leaks have been controlled, it is important to determine how well the remaining lung fills the pleural space. Complete reapproximation of the visceral pleura to the parietal pleura helps to reduce PAL [1]. We routinely mobilize the lung to allow it to fully expand, including dividing the inferior pulmonary ligament and carefully lysing any intrapleural adhesions that are present. If the remaining lung does not adequately fill the pleural cavity even after complete mobilization, there are various techniques available to reduce the volume of the pleural cavity. Upper lobectomy and bilobectomy have been associated with an increased risk of PAL [2, 12, 30]. To decrease the risk of PAL, a pleural tent may be created at the apex of the thoracic cavity, in an attempt to reapproximate the parietal pleura to the visceral pleura at the apex. An extrapleural dissection is performed to create a space between the parietal pleura and the chest wall. The pleura is then reattached lower on the chest wall, decreasing the volume of the pleural cavity [50]. Multiple well-designed randomized studies have found that creation of an apical pleural tent can decrease the frequency of PAL and length of stay after upper lobectomy, without an increase in other complications [51-54]. Several high-volume centers advocate routine use of pleural tents after upper lobectomy [55, 56]. However, most surgeons do not create pleural tents after every upper lobectomy, citing fear of infectious or hemorrhagic complications or decreased long-term lung capacity, and prefer to reserve the pleural tent for patients at particularly high risk for PAL [57]. After lower lobectomy, elevation of the ipsilateral hemidiaphragm may decrease the volume of the pleural cavity and allow for reapproximation of the visceral and parietal pleura. One technique to elevate the diaphragm is to create an iatrogenic pneumoperitoneum, either percutaneously postoperatively [58, 59] or by injecting air directly through the diaphragm interoperatively [60]. Both techniques have been associated with decreasing length or frequency of PAL in small case series. While crushing of the phrenic nerve is no longer advocated, another method to elevate the ipsilateral hemidiaphragm is to induce temporary paralysis of the phrenic nerve, either by injection of longacting local anesthetic (a technique used by our group), or by continuous infusion with a short-acting local anesthetic [61]. Rather than advocate routine use of measures to reduce the volume of the pleural space we, along with others [45], suggest that the various techniques be kept in mind for use in selected patients at high risk for PAL. Identifying and assessing air leaks in the operating room can be challenging with a video-assisted or robotic approach, and occasionally even with open lung resection. At the end of the operation, the surgeon should always assess the extent of air leak through the chest tube collection system after the chest is closed. An unexpectedly large or continuous air leak identified after closure should be reason to consider reopening while the patient is still under anesthesia and the field is still sterile. POSTOPERATIVE TECHNIQUES FOR MANAGING PROLONGED AIR LEAK Despite careful technical attention to techniques to ensure pneumostasis, some patients will still develop PAL postoperatively. Most leaks will resolve without reoperation [2, 4, 25, 26, 62]. Multiple randomized trials have evaluated the best strategy for chest tube management to reduce PAL after lung resection [39, 55, 63-65]. They have consistently supported the use of less suction (alternating water seal during the day and -10cm H 2 O suction overnight [39, 55]) or early use of water seal [63-65] for managing patients with an air leak, even in patients with a small pneumothorax [66]. Current treatment guidelines recommend the early use of water seal for management of postoperative air leaks, except when an expanding pneumothorax or new symptoms such as subcutaneous emphysema or dyspnea develop on water seal [1, 2, 24, 31, 45, 66-70]. When a PAL develops, several strategies can be used to attempt to stop the leak without reoperation. Most PALs will resolve if given enough time. A cost-effective and safe strategy for management of the asymptomatic PAL is to attach a one-way valve or a compact drainage device to the chest tube and, if this is tolerated, discharge the patient from the hospital with the chest tube in place [1, 71]. The chest tube can be removed in clinic 14 days later, even if the air leak continues [72]. Several authors recommend provocative clamping of the persistently leaking chest tube prior to its removal, to see whether drainage of the air leak is necessary [27, 33, 73]. If a clamping trial produces symptoms or an expanding pneumothorax, then sclerosis can be attempted. Many different types of intrapleural sclerosants have been evaluated for management of PAL: talc, betadine, various antibiotics, dextrose, and autologous blood have all been used successfully to seal PAL when infused through the chest tube [24, 45]. Several authors have reported successful bronchoscopic placement of endobronchial one-way valves to stop PAL [74, 75].

4 Prolonged Air Leak Current Respiratory Medicine Reviews, 2012, Vol. 8, No Reoperation for PAL is a rare event, because most leaks seal spontaneously with conservative measures. However, some patients with recalcitrant PAL will eventually require operative reintervention. In most series of patients with PAL, the incidence of reoperation for PAL is <2% [12, 45, 58]. Reoperation on a patient with PAL is perilous: adhesions are usually present from the initial surgery, prolonged chest tube drainage, and chronic contamination of the pleural space. The patient still has the risk factors that initially put him or her at high risk for PAL, and wound healing is further compromised by the malnutrition associated with trying to heal a PAL. Reoperation is the time to liberally employ the strategies already discussed: when appropriate we buttress staple lines, employ sealants, and use techniques to decrease the size of the pleural space. Several other techniques for reducing the volume of the pleural cavity are available in this scenario: it is possible to fill the space with flaps of omentum or muscle or to reduce the volume of the bony thorax by thoracoplasty. CONCLUSION PAL has been repeatedly identified as the most common complication and the most common cause of delay of discharge after thoracic surgery [5-7, 10-13, 15, 21, 25]. PAL is associated with increased morbidity and increased cost [4, 7]. It is important to identify the patients at highest risk for PAL: those with significant emphysema, at risk for poor wound healing, and/or undergoing resection of large volumes of lung. Once patients at high risk for PAL are identified, various strategies may be used intraoperatively and postoperatively to decrease the risk for PAL and its associated morbidity and cost. Best efforts should be directed at minimizing and controlling air leaks in the operating room whenever possible. 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