Chemical pleurodesis in the presence of persistent air leak

Thickened parietal pleural covering in intractable pneumothorax: A case report

Introduction and importance

Choosing the optimal surgical approach for intractable pneumothorax can be challenging for surgeons.

Case presentation

A case describing the management of intractable pneumothorax has been presented.

Clinical discussion

Resection is not suitable in a stiff lung from repeated pleurodesis, and multiple air leakage points would make it more intricate.The ideal alternative is the use of another material to cover the entire lesion.

Conclusion

A thickened parietal pleura covering is an effective surgical approach for intractable pneumothorax.

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Selecting an optimal surgical approach for intractable pneumothorax is challenging.

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A thickened parietal pleura covering can effectively control intractable pneumothorax.

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The procedure is suitable for patients with stiff lung and persistent air leakage at multiple points.

Management of air leaks post-surgical lung resection

Airleaks are one of the most common complications associated with elective lung resection. There have been many techniques and modern advancements in thoracic surgery, however airleaks persist. This review article will discuss several interventions ranging from conservative noninvasive to surgical management of the persistent airleak. These techniques include stopping of suction on the plueravac, fibrin patches, pleurodesis, use of endobronchial valves (EBVs), return to OR for operative intervention, and lastly to send patients home with mini pleuravacs.

Retrospective evaluation of the use of autologous blood-patch treatment for persistent pneumothorax in 8 dogs (2009-2012)

OBJECTIVE

To describe the clinical course, outcome and success rate of 8 dogs with persistent pneumothorax treated with autologous blood-patch pleurodesis (ABP).

DESIGN

Retrospective case series.

SETTING

University teaching hospital

ANIMALS

Eight client-owned dogs.

INTERVENTION

Non-coagulated blood was aseptically collected from the jugular vein and injected immediately into the pleural cavity of dogs with persistent pneumothorax.

MEASUREMENTS AND MAIN RESULTS

The procedure was successful in 7 of 8 dogs. The median duration of pneumothorax until the ABP was performed was 4 days (range 2-6 days). Pneumothorax resolved immediately after 1 treatment in 4 dogs. Pleurodesis was repeated once in 3 dogs, and twice in 1 case after which it resolved in 3 of the 4 dogs. Out of a total of 13 ABP procedures performed in 8 dogs, 5 (62.5%) were successful after 1 procedure and the success rate increased to 87.5% after additional procedures. One dog failed ABP and was euthanized 3 days later due to continued deterioration and a hospital acquired pneumonia. Mild to moderate complications occurred in 2 other dogs and resolved in both.

CONCLUSIONS

ABP is a simple, inexpensive, and relatively safe procedure which can be considered in dogs with persistent pneumothorax that have failed conservative or surgical management. Infections following ABP were documented in 2 of the 8 dogs and resolved in 1 dog.

Autologous blood pleurodesis: A good choice in patients with persistent air leak

AIM

The study compares the efficiency, side effects and complications of autologous blood pleurodesis with talcum powder and tetracycline.

MATERIALS AND METHODS

This prospective study evaluated 50 patients with persistent air leak resulting from primary and secssondary spontaneous pneumothorax between February 2004 and March 2009. The patients inclussded 32 (64.0%) males and 18 (36.0%) females with a median age of 39 years (range 14-69 years). All cases had persistent air leak of more than seven days. Pleurodesis was performed using autologous blood in 20 (40.0%) patients, talc powder in 19 (38.0%) patients and tetracycline in 11 (22.0%) patients through a chest tube. Air leak cessation times after pleurodesis, side effects and pulmonary function tests (PFT) in the first and third months were measured.

RESULTS

Recurrent primary spontaneous pneumothorax was the cause of persistent air leak in all cases. Air leaks were expiratory only in 54.0% of cases. We obtained a success rate of 75.0% using autologous blood, 84.2% using talc powder and 63.6% using tetracycline. Mean air leak termination interval was significantly (P < 0.001) shorter in patients treated with autologous blood in comparison to talc powder and tetracycline. We observed a significant (P < 0.05) decline in PFT in patients treated with talc powder compared with tetracycline and autologous blood. Vital capacity, FVC and FEV₁were significantly lower in patients treated with tetracycline compared with autologous blood.

CONCLUSION

This study shows that autologous blood pleurodesis compared to talc powder and tetracycline is related with shorter leak cessation time and less pulmonary function decline in patients with persistent air leak. We think further randomized clinical trials of pleurodesis as treatment could increase its use in thorax surgery by demonstrating the safety and the efficacy of this procedure.

Efficacy of blood-patch pleurodesis for secondary spontaneous pneumothorax in interstitial lung disease

OBJECTIVE

We identified the prognostic relevance of pneumothorax in interstitial lung disease (ILD) patients and evaluated the efficacy and safety of autologous blood-patch pleurodesis.

METHODS

We retrospectively reviewed 59 occurrences of pneumothorax in 34 ILD patients identified over a 12-year period.

RESULTS

Air leakage ceased in 16 of 22 (72.7%) episodes after blood pleurodesis and in 11 of 14 (78.6%) episodes after chemical pleurodesis. Both the cure ratio and recurrence ratio in the cure episodes were comparable with those in the chemical pleurodesis group (p=0.99 and 0.99, respectively). In addition, there were no harmful events associated with blood pleurodesis. The median survival time after the first episode of pneumothorax was less than 9 months in patients with idiopathic interstitial pneumonia (IIP) and only around 3 years in the patients with other types of ILD, which have essentially favorable outcomes. Kaplan-Meier survival estimates were significantly worse in the patients with concomitant pneumomediastinum than in those without (p<0.05). A multivariate Cox regression analysis identified that the number of episodes of pneumothorax, IIP diagnosis and concomitant pneumomediastinum were independent predictors of death.

CONCLUSION

Autologous blood-patch pleurodesis is safe and worth considering as a first-line treatment for pneumothorax secondary to ILD. However, despite treatments, the prognosis after the onset of pneumothorax in ILD patients was found to be poor. In addition, concomitant pneumomediastinum may further worsen the prognosis.

Resolution of persistent pneumothorax by use of blood pleurodesis in a dog after surgical correction of a diaphragmatic hernia

CASE DESCRIPTION

A 15-kg (33-lb) pregnant female mixed-breed dog of unknown age was referred because of a 10-day history of difficulty breathing.

CLINICAL FINDINGS

Physical examination findings were dyspnea, tachypnea, decreased bronchovesicular sounds (bilateral), muffled heart sounds, and abdominal distention with palpable fetuses. Hematologic abnormalities included anemia, leukocytosis, and thrombocytosis. Abnormalities detected during serum biochemical analysis included decreases in concentrations of albumin, sodium, triglycerides, and total calcium and increases in activities of alkaline phosphatase, alanine aminotransferase, gamma-glutamyltransferase, aspartate aminotransferase, lactate dehydrogenase, and creatine kinase. Thoracic radiography revealed a diaphragmatic hernia with fetuses and a soft tissue or fluid opacity within the thoracic cavity.

TREATMENT AND OUTCOME

Exploratory celiotomy, ovariohysterectomy, partial sternotomy, placement of a right-sided thoracostomy tube, and herniorrhaphy were performed. After surgery, pneumothorax developed, and the thoracostomy tube was used to remove pleural effusion and free air. The pneumothorax did not resolve after continuous drainage of the thoracic cavity for 4 days. Autologous blood pleurodesis was performed by infusion of 80 mL (6 mL/kg [2.73 mL/lb]) of whole blood. The pneumothorax resolved immediately after injection of the blood.

CONCLUSIONS AND CLINICAL RELEVANCE

Blood pleurodesis was used for resolution of pneumothorax in a dog after correction of a diaphragmatic hernia. Blood pleurodesis may provide a simple, safe, and inexpensive medical treatment for resolution of persistent (duration>5 days) pneumothorax when surgery is not an option.

Pleurodesis with an autologous blood patch to prevent persistent air leaks after lobectomy

OBJECTIVE

Air leakage after pulmonary lobectomy is a well-known problem often contributing to extended hospitalization. Many techniques have been proposed to prevent and treat air leakage, but none have been proved incontrovertibly effective. We evaluated the role of an autologous blood patch after pulmonary lobectomy.

METHODS

Twenty-five patients with air leaks on the sixth postoperative day after lobectomy were enrolled in this study. They were randomly assigned to 2 groups: group A (12 patients), with 50 mL of autologous blood infused in the pleural cavity; and group B (13 patients), with 100 mL of blood infused. These 2 groups were retrospectively compared with the last 15 patients showing the presence of air leaks for at least 6 days (group C) (in this group the duration of leakage after the sixth postoperative day was compared). We recorded the duration of posttreatment air leaks and hospitalization.

RESULTS

Air leaks stopped 2.3 +/- 0.6 days after the procedure in group A, 1.5 +/- 0.6 days after the procedure in group B, and after 6.3 +/- 3.7 days in group C. The air leakage disappeared within 72 hours in all patients in groups A and B. There was a statistically significant difference in the duration of drainage between groups A and B (P = .005), groups A and C (P = .0009), and groups B and C (P = .0001), showing the effectiveness of an autologous blood patch, particularly with 100 mL of blood.

CONCLUSIONS

Management of air leaks after lobectomy with an autologous blood patch is easy, safe, and effective, and does not add costs. It may become the gold standard treatment early in the postoperative course.

Autologous blood patch in persistent air leaks after pulmonary resection

OBJECTIVE

Persistent air leak is among the most common complications after pulmonary resection, leading to prolonged hospitalization and increased costs. At present there is not yet a consensus on their treatment.

METHODS

During a 7-year experience, 21 patients submitted to pulmonary resection were postoperatively treated with an autologous blood patch for persistent air leaks. Persistent air leaks were catalogued twice daily according to the classification previously reported by Cerfolio and associates. Chest radiographs showed a fixed pleural space deficit in 18 (86%) patients. A total of 50 to 150 mL of autologous blood was drawn from the patient and injected into the chest tube, which was removed 48 hours after cessation of the air leak.

RESULTS

We observed a 4% incidence of persistent air leaks after pulmonary resection in our series. Persistent air leaks were categorized as follows: 14% forced expiratory, 57% expiratory, 29% continuous, and 0% inspiratory. The mean duration of prolonged air leaks was 11 days after surgery. In 81% of the cases examined, a blood patch was only carried out once and gave successful results within 24 hours. In the remaining 19% of cases, the air leak ceased within 12 hours after the second procedure. Mean hospital stay was 15 days. In our experience this procedure had a 100% success rate.

CONCLUSIONS

Pleurodesis with an autologous blood patch is well tolerated, safe, and inexpensive. This procedure is an effective technique for treatment of postoperative persistent air leaks, even in the presence of an associated fixed pleural space deficit.

A DIFFERENT APPLICATION METHOD OF TALC PLEURODESIS FOR THE TREATMENT OF PERSISTENT AIR LEAK

Persistent air leak is a serious problem that may cause empyema, hypoxia, respiratory insufficiency, and other life-threatening complications. Chemical pleurodesis may be carried out for the treatment of persistent air leak if the lung is fully expanded. However, the standard method of chemical pleurodesis entails clamping the chest tube for a period of time after instillation of the agent. In patients with massive air leak, this would result in a tension pneumothorax. Therefore, standard chemical pleurodesis for persistent air leak is not an appropriate treatment for these patients. In this study, we carried out talc pleurodesis in six patients using an inverted U-shaped chest tube elevated to 60 cm that did not result in tension pneumothorax and mediastinal shift. No recurrence was observed during a mean follow up of 16.2 months.

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

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.

Centromere DNA, proteins and kinetochore assembly in vertebrate cells

The centromere is a specialized region of the chromosome that is essential for faithful chromosome segregation during mitosis and meiosis in eukaryotic cells. It is the site at which the kinetochore, the functional nucleoprotein complex responsible for microtubule binding and chromosome movement, is assembled through complex molecular mechanisms. Herein, I review recent advances in our understanding of centromeric DNAs as sites for kinetochore assembly and the mechanisms underlying kinetochore assembly in vertebrate cells.

Effects of Additional Minocycline Pleurodesis After Thoracoscopic Procedures for Primary Spontaneous Pneumothorax

STUDY OBJECTIVE

To evaluate the safety and efficacy of additional minocycline pleurodesis after thoracoscopic treatment of primary spontaneous pneumothorax.

DESIGN

Retrospective comparative study with a historical control.

SETTING

Thoracic surgical division of a university-affiliated tertiary medical center.

PATIENTS AND METHODS

Between April 1994 and April 2001, 313 consecutive patients (minocycline group) with primary spontaneous pneumothorax were treated by video-assisted thoracoscopic surgery. The procedures included resection of the blebs and mechanical pleurodesis by scrubbing the parietal pleura. After operation, minocycline hydrochloride, 7 mg/kg, was instilled into the pleural space through a thoracostomy tube. The control group consisted of 51 consecutive patients who underwent the same thoracoscopic procedures alone for primary spontaneous pneumothorax between January 1992 and April 1994.

RESULTS

There was no significant difference between the two groups in terms of demographic data, operative findings, and operation time. Chest pain was a common complaint after minocycline pleurodesis, but the total doses of requested analgesics were comparable in both groups. The rate of prolonged air leaks was significantly lower in the minocycline group (7.0% vs 17.6%, p = 0.025). Patients treated with minocycline had shorter periods of postoperative chest drainage and hospitalization. The ipsilateral recurrence rate was also significantly lower in these patients (2.9% vs 9.8%, p = 0.033).

CONCLUSIONS

Minocycline pleurodesis is a safe and convenient procedure that may improve the outcome and reduce the rate of recurrence after thoracoscopic treatment for primary spontaneous pneumothorax. A randomized control study may be needed to confirm the findings.

Postsurgical pleurodesis with autologous blood in patients with persistent air leak

BACKGROUND

Persistent air leak after operation on the lung is one of the most common problems encountered by thoracic surgeons. We present 6 patients who underwent pleurodesis with autologous blood for persistent air leak after operation.

METHODS

Between June 1993 and January 1998, pleurodesis with autologous blood was performed in 6 patients who had air leak of more than 10 days' duration after operation for non-small cell lung cancer. A sample of peripheral blood was taken from the patient's arm and immediately introduced into the chest tube with no additives. The chest tube was left unclamped and off suction, connected to the waterseal drainage, and kept 60 cm above the patient's chest. The next day, the waterseal and chest roentgenogram were reviewed before the chest tube was removed.

RESULTS

A persistent air leak with a mean duration of 16.7 days was observed after the initial operation. Fifty to 250 mL of blood was introduced one time into the chest tube. No patient experienced pain, respiratory difficulty, fever, or episodes of coughing during the procedure. After 24 hours, no air leak was detected in the waterseal drainage in any patient.

CONCLUSIONS

On the basis of these preliminary findings, we believe pleurodesis with autologous blood is a safe and effective method for treating persistent air leak after a thoracic surgical procedure.

Pneumoperitoneum to treat air leaks and spaces after a lung volume reduction operation

Lung volume reduction surgery is an option for the management of end-stage emphysema. The most frequent surgical complication of lung volume reduction is prolonged air leaks. We describe a patient undergoing a lung volume reduction operation complicated by persistent bilateral air spaces with large air leaks. Treatment with recurrent pneumoperitoneum via a peritoneal dialysis catheter along with chemical sclerosis successfully resolved both problems.

Spontaneous pneumothorax: A retrospective study of twenty-five patients and literature review

We present a retrospective study of 25 patients with spontaneous pneumothorax (three current), comprising 16 Saudis (nine males and seven females) and nine non-Saudis (eight males and one female), seen at the Asir Central Hospital, Abha, over a period of 45 months. Almost one-third of the patients (9/25) had no underlying cause discernible by our investigational facilities (chest x-ray, ultrasonography, computed tomographic scan, and flexible bronchofiberscopy). Underlying pneumonia (three patients), pulmonary tuberculosis (two patients), lung abscess (one patient), and congenital bullae (one patient) constituted the etiology in another third of the spontaneous pneumothorax patients. Other underlying pulmonary diseases precipitating spontaneous pneumothorax in the group included pulmonary fibrosis, metastatic mesothelioma, and immunosuppression in a medulloblastoma patient undergoing chemotherapy with the development of chickenpox. Closed thoracostomy tube drainage was the only method of treatment in 20 out of the 25 patients, with three failures of closed thoracostomy tube drainage needing thoracotomy and resection of blebs/bullae. The only complication was empyema in two of the patients. Two patients were successfully treated conservatively with observation alone.

Intrapleural quinacrine instillation for recurrent pneumothorax or persistent air leak

From 1982 to 1990, 27 patients with recurrent pneumothorax or persistent air leak (28 episodes) underwent pleurodesis with intrapleural administration of quinacrine, according to a standardized scheme. A first evaluation was done about 1 month after the intervention. In August 1990, all patients were invited for a second check-up. In 4 patients quinacrine plasma concentrations were determined. There was one early failure. No late recurrences were observed. Neither serious nor late complications were seen with our low-dose regimen. Transient fever was the only constant side effect. In contrast to other chemicals proposed for pleurodesis, quinacrine did not cause major pain. Only very low quinacrine plasma concentrations (peak, < 10 ng/mL) were found. In conclusion, chemical pleurodesis with quinacrine can be considered a safe and effective treatment. The number of administrations as well as the dosage are important to prevent morbidity and recurrence.

Long-term results after tetracycline pleurodesis in spontaneous pneumothorax

From 1979 to 1988 483 patients were admitted with primary spontaneous pneumothorax. All patients underwent thoracoscopy to identify the cause of pneumothorax. Chemical pleurodesis with instillation of tetracycline was performed if cysts less than 2 cm in diameter were found. If larger cysts were identified the patient underwent thoracotomy. In 93 patients with cysts larger than 2 cm the recurrence rate after thoracotomy was 4%. In 390 patients treated with intrapleural instillation of tetracycline, the recurrence rate was 16%. Fifty percent of the recurrences occurred within 30 days. The cause of recurrence in 42 patients (69%) was cysts missed at the initial thoracoscopy. This study has demonstrated that thoracoscopy is a reliable and safe method for selection of patients for chemical pleurodesis. It is, however, necessary that the thoracoscopy is meticulous to avoid recurrence from missed cysts.

Autologous "blood patch" pleurodesis for persistent pulmonary air leak

A persistent pulmonary air leak, whether as a result of pulmonary surgery or as a result of a traumatic or spontaneous pneumothorax, is a difficult and frustrating problem to manage. Several therapies have been employed, including thoracotomy and repair of the air leak, prolonged tube thoracostomy suction, and chemical pleurodesis. We report two cases in which patients with a prolonged air leak who were not candidates for thoracotomy had immediate successful treatment with an autologous "blood patch" pleurodesis. An autologous blood patch pleurodesis is, in our limited experience, a simple, painless, inexpensive, and effective treatment for patients with a persistent pulmonary air leak.