[Persistent air leak (PAL): conservative vs. invasive approach?]

Abstract

Introduction: An air leak following pulmonary resection is generally defined as persistent, or prolonged, if it fails to resolve within the first post-operative week. The precise definition has varied from study to study.

State of art: Persistent air leak represents the most frequent complication in patients undergoing general thoracic procedures. The groups most at risk are elderly patients, patients with chronic obstructive pulmonary disease (COPD), and those who have general risk factors such as diabetes mellitus or who are taking oral steroids. The surgical procedures most commonly affected are upper lobectomies and lung volume reduction surgery for end-stage emphysema.

Perspectives: Technically, performing a pleural tent at the time of an upper lobectomy may decrease the incidence of prolonged air leak. Reinforcement or buttressing of the staple line has been shown to decrease both the incidence and the duration of air leaks, but this increases costs and should thus be reserved for patients with lung parenchyma at the highest risk. The use of biological glues can be helpful in reducing the duration of chest tube drainage when applied intraoperatively for moderate and/or severe parenchymal air leaks, however, their systematic use in not recommended. The management of chest tube drainage after pulmonary resection varies widely from one institution to another. Most recent reports have favoured early discontinuation of negative pressure drainage and a move to underwater seal drainage (from the second post-operative day), however, no large scale randomised study is yet available to compare this with a more conservative approach.

Conclusions: The management of persistent air leak following surgery requires identification of risk factors, good surgical technique and appropriate chest tube management.