Intraoperative and Postoperative Management of Air Leaks in Patients with Emphysema

Endobronchial silicone spigot in prolonged air leaks: Nationwide study on outcomes and risk factors for treatment failure

BACKGROUND

The endobronchial silicone spigot, also known as the endobronchial Watanabe spigot, is used in bronchoscopic interventions to manage prolonged pulmonary air leakage. However, the outcomes of this procedure have not been thoroughly investigated.

METHODS

Using a Japanese national inpatient database from April 2014 to March 2022, we assessed the clinical characteristics and outcomes of all eligible patients who received the endobronchial spigot. We also investigated risk factors associated with treatment failure. Treatment failure was defined as in-hospital death or the need for surgery after bronchial occlusion.

RESULTS

We analyzed data of 1095 patients who underwent bronchial occlusion using the endobronchial spigot. Among them, 252 patients (23.0%) died during hospitalization, and 403 patients (36.8%) experienced treatment failure. Factors associated with treatment failure included age between 85 and 94 years (odds ratio [OR] 1.83; 95% confidence intervals [CI], 1.04-3.21); male sex (OR 2.43; 95% CI, 1.44-4.11); low Barthel index score; comorbidities of interstitial pneumonia (OR 1.71; 95% CI, 1.18-2.48); antibiotics treatment (OR 1.45; 95% CI, 1.02-2.07); steroids treatment (OR 1.59; 95% CI, 1.07-2.36); and surgery prior to bronchial occlusion (OR 2.08; 95% CI, 1.29-3.35). In contrast, pleurodesis after bronchial occlusion (OR 0.49; 95% CI, 0.32-0.75), and admission to high-volume hospitals were inversely associated with treatment failure (OR 0.58; 95% CI, 0.37-0.90).

CONCLUSIONS

The endobronchial Watanabe spigot could be a nonsurgical treatment option for patients with prolonged pulmonary air leaks. Our findings will help identify patients who may benefit from such bronchial interventions.

Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery

PURPOSE

Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks.

METHODS

This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks.

RESULTS

Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days).

CONCLUSIONS

This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.

Bronchoscopic valve placement for the treatment of persistent air leaks

Persistent air leaks (PALs) are associated with increased morbidity, prolonged hospital stay, and increased treatment costs. Endobronchial 1-way valves have been recently used as a potential less invasive treatment option. We sought to investigate the effects of valve therapy in treating this condition. The patients with evidence of continuous air leak flow whose chest tubes remained in place for more than 7 days were treated with bronchoscopic closure using 1-way valves. The source of the air leak was identified by the Chartis system.A total of 11 patients (1 woman, 10 men; mean age, 68 years) who underwent valve placement were eligible to be enrolled from January 2015 through January 2017. Six patients had postoperative PAL, and 5 had a secondary spontaneous pneumothorax. The number of used valves varied from 1 to 3 (median 1). The resolution of the leak was complete in 8 patients (72.7%), whose mean duration of air leak before and after valve deployment was 58.5 and 4.5 days, respectively. There were no complications related to the valve deployment.Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PALs. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

Management of Prolonged Pulmonary Air Leaks With Endobronchial Valve Placement

Background:

Prolonged pulmonary air leaks (PALs) are associated with increased morbidity and extended hospital stay. We sought to investigate the role of bronchoscopic placement of 1-way valves in treating this condition.

Methods:

We queried a prospectively maintained database of patients with PAL lasting more than 7 days at a tertiary medical center. Main outcome measures included duration of chest tube placement and hospital stay before and after valve deployment.

Results:

Sixteen patients were eligible to be enrolled from September 2012 through December 2014. One patient refused to give consent, and in 4 patients, the source of air leak could not be identified with bronchoscopic balloon occlusion. Eleven patients (9 men; mean age, 65 ± 15 years) underwent bronchoscopic valve deployment. Eight patients had postoperative PAL and 3 had a secondary spontaneous pneumothorax. The mean duration of air leak before valve deployment was 16 ± 12 days, and the mean number of implanted valves was 1.9 (median, 2). Mean duration of hospital stay before and after valve deployment was 18 and 9 days, respectively (P = .03). Patients who had more than a 50% decrease in air leak on digital monitoring had the thoracostomy tube removed within 3–6 days. There were no procedural complications related to deployment or removal of the valves.

Conclusions:

Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PAL. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage

BACKGROUND

A persistent air leak represents significant clinical management problems, potentially affecting morbidity, mortality, and health care costs. In 2008, a unidirectional, intrabronchial valve received humanitarian device exemption for use in managing prolonged air leak after pulmonary resection. Since its introduction, numerous reports exist but no large series describe current utilization or outcomes. Our aim was to report current use of intrabronchial valves for air leaks and review outcome data associated with its utilization.

METHODS

A multicenter, retrospective review of intrabronchial valve utilization from January 2013 to August 2014 was performed at eight centers. Data regarding demographics, valve utilization, and outcomes were analyzed.

RESULTS

We identified 112 patients undergoing evaluation for intrabronchial valve placement, with 67% (75 of 112) undergoing valve implantation. Nearly three quarters of patients underwent valve placement for off-label usage (53 of 75). A total of 195 valves were placed in 75 patients (mean 2.6 per patient; range, 1 to 8) with median time to air leak resolution of 16 days (range, 2 to 156).

CONCLUSIONS

We present the largest, multicenter study of patients undergoing evaluation for intrabronchial valve use for air leak management. Our data suggest the majority of intrabronchial valve placements are occurring for off-label indications. Although the use of intrabronchial valves are a minimally invasive intervention for air leak management, the lack of rigorously designed studies demonstrating efficacy remains concerning. Prospective randomized controlled studies remain warranted.

Quantative computerized tomography assessment of lung density as a predictor of postoperative pulmonary morbidity in patients with lung cancer

BACKGROUND

The aim of this study was to evaluate the pulmonary reserve of the patients via preoperative quantitative computerized tomography (CT) and to determine if these preoperative quantitative measurements could predict the postoperative pulmonary morbidity.

METHODS

Fifty patients with lung cancer who underwent lobectomy/segmentectomy were included in the study. Preoperative quantitative CT scans and pulmonary function tests data were evaluated retrospectively. We compare these measurements with postoperative morbidity.

RESULTS

There were 32 males and 18 females with a mean age of 54.4±13.9 years. Mean total density was -790.6±73.4 HU. The volume of emphysematous lung was (<-900 HU) 885.2±1,378.4 cm(3). Forced expiratory volume in one second (FEV1) (r=-0.494, P=0.02) and diffusion capacity of carbon monoxide (DLCO) (r=-0.643, P<0.001) were found to be correlate with the volume of emphysematous lung. Furthermore FEV1 (r=0.59, P<0.001) and DLCO (r=0.48, P<0.001) were also found to be correlate with mean lung density. Postoperative pulmonary morbidity was significantly higher in patients with lower lung density (P<0.001), larger volume of emphysema (P<0.001) and lower DLCO (P=0.039). A cut-off point of -787.5 HU for lung density showed 86.96% sensitivity and 81.48% specificity for predicting the pulmonary morbidity (kappa =-0.68, P<0.001). Additionally a cut-off point of 5.41% for emphysematous volume showed 84.00% sensitivity and 80.00% specificity for predicting the pulmonary morbidity (kappa =0.64, P<0.001). According to logistic regression analyses emphysematous volume >5.41% (P=0.014) and lung density <-787.5 HU (P=0.009) were independent prognostic factors associated with postoperative pulmonary morbidity.

CONCLUSIONS

In this study, the patients with a lower lung density than -787.5 HU and a higher volume of emphysema than 5.41% were found to be at increased risk for developing postoperative pulmonary morbidity. More stringent precautions should be taken in those patients that were found to be at high risk to avoid pulmonary complications.

Clinical usefulness of free subcutaneous fat pad for reduction of intraoperative air leakage during thoracoscopic pulmonary resection in lung cancer cases

INTRODUCTION

Intraoperative alveolar air leaks remain a significant problem in thoracoscopic surgery (TS) cases. We examined the usefulness of covering damaged lung tissue with a subcutaneous fat pad for preventing postoperative air leakage in patients with non-small cell lung cancer (NSCLC).

METHODS

Patients with NSCLC underwent a thoracoscopic lobectomy or segmentectomy. When alveolar air leakage from the superficial pulmonary parenchyma was found, fibrin glue in combination with an absorbable mesh sheet was applied (S group; n = 100). When leakage originated from deep within the pulmonary parenchyma, a subcutaneous fat pad about 2 × 2 cm in size was harvested from the utility incision and placed on the damaged lung tissue with fibrin glue and sutures (F group; n = 66). Patient characteristics, air leak duration, and chest-tube removal time were analyzed.

RESULTS

The homogeneity of each group was consistent, with no statistical differences for age, respiratory function, surgical procedures, pathologic stage, and histological type. The air leak duration was significantly shorter (p = 0.015), and the chest tube was removed significantly earlier (p = 0.002) in patients in the F group.

CONCLUSION

Use of a free subcutaneous fat pad during pulmonary resection for TS patients with NSCLC reduced the duration of air leakage and chest tube drainage. The present method is easy, safe, and effective for repairing an air leak from remaining lung tissues in such cases.

A simple technique to avoid postoperative air leakages after right upper lobectomy

A simple technique to complete interlobar fissures during right upper lobectomy is described. After closing and sectioning the vein, the arteries and the bronchus, the residual lung is gently inflated to visualize the border with the upper lobe. The parenchyma is stapled (GIA 75) at the level of the first non-ventilated part of the upper lobe. This method allows placing the parenchymal stapler line in a fully non-ventilated zone. Since at this level there should be no air, no air leakages are expected during the postoperative course. This technique was performed in 15 patients undergoing right upper lobectomy and no postoperative air leakage was observed.