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Ways to Reduce, Treat and Measure Air Leaks After Pulmonary Resection

Ways to Reduce, Treat and Measure Air Leaks After Pulmonary Resection. Robert J. Cerfolio, MD, MBA, FACS, FCCP JH Estes Endowed Chair Lung Ca Research Professor of Surgery Chief of Thoracic Surgery, UAB. Future of Thoracic Surgery Financial Disclosure. Conflict of interest:

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Ways to Reduce, Treat and Measure Air Leaks After Pulmonary Resection

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  1. Ways to Reduce, Treat and Measure Air Leaks After Pulmonary Resection Robert J. Cerfolio, MD, MBA, FACS, FCCP JH Estes Endowed Chair Lung Ca Research Professor of Surgery Chief of Thoracic Surgery, UAB

  2. Future of Thoracic SurgeryFinancial Disclosure • Conflict of interest: • Received honorarium from Intuitive - make the only FDA approved robotic system • Also I devised PRIIME … • Also done studies for Digivent, Thopaz and Atmos

  3. Air LeaksIntroduction • Air leaks (A/L) most common complication pulmonary surgery • Few studies on A/L’s, no classification system • For past 10 yrs studied this problem, along few others - Brunelli

  4. Air LeaksRDC Classification System • Qualitative: Describe air leaks continuous, expiratory, inspiratory, or forced expiratory • Quantitative: Air leak meter was commercial available, reliable and reproducible between different observers, labelled leaks 1 - 7 (1 smallest)

  5. Air LeaksView problem Air Leaks • Conceptualize problem air leaks: • (1) pre-operative risk factors predict • (2) intra-operative techniques prevent • (3) early post-operative techniques seal • (4) treatment of persistent air leaks and pleural space problems

  6. Air LeaksOverview of Database • Armed with this background, able briefly summarize our findings • These findings based mainly on many studies, 4 well-known : 1st N=101, 2nd – 140, 3rd – 66, 4th -1,062 • All prospective randomized trials, IRB approval at UAB, statistical analysis

  7. Air LeaksFramework

  8. Air LeaksPrevention • Best Rx of A/L is prevention • Prevention starts in OR • “Fissure-less technique” • Ligating vessels hilum, avoids fissure – like VATS lobes or robotic

  9. Air LeaksOther Intra-op Techniques • Other techniques OR - pericardial strips, pinpointing A/L’s and suturing them • Control the pleural space - pleural tents, pneumoperitoneum, sealants • Careful placement of CT’s • Despite all these efforts, 10 - 30% pt A/L

  10. Air LeaksPneumoperitoneum • Pleural tents … Pneumoperitoneum – good technique control lower hemithorax problems • Annals Thor Surg 2000 prospective randomized trial after bilobectomy • Examined 16 patients underwent bi-lobectomy (RM+RLL) found placing 1200 cc under diaphragm time surgery, prevents A/L

  11. Air LeaksTypes of Air Leaks • If A/L post-op – ensure from pt’s lung and not system, then determine type A/L • Ensure A/L is “alveolar-pleural” fistula and not broncho-pleural fistula • Once know it’s former, then characterize it, use a classification system and treat it non-operatively • Takes us to several props trials done….

  12. Air LeaksFramework

  13. Air Leaks - FutureDigital Air Leak Digital system measures exact ml/hr of air leak, each breath

  14. Air Leaks - FutureDigital Air Leak ATMOS ……. Digital air leak system Measures , each breath ml/min

  15. Philosophy Mobility Thopaz

  16. Air LeaksSummaries Prospective Trials • Most all A/L’s are expiratory • Most A/L’s small and get smaller on water seal • Suction makes A/L’s larger and delays them from healing • A/L are more likely to resolve with CT placed on water seal than wall suction

  17. Air LeaksAlgorithm -Summary • Day of surgery – lobectomy -1 CT (Evidence based) • Suction day surgery (Preference) • POD 1 -3: water seal if no pneumo, no subQ air (evidence based) • Removal of CT – 450 cc/ day or less, not chyle or blood or CSF (evidence based)

  18. Air LeaksManagem. Pneumothorax+A/L • Study publication, examined 1,062 patients, 66 of whom had a concomitant air leak and pneumothorax • Found, water seal best if A/L small < E-3 • Pneumothoraces, in general best left alone, NOT indication place suction on CT’s, esp pt with an A/L • Indication suction – Sx pneumo, subQ air

  19. Air LeaksManagem. Pneumothorax+A/L • Only need add suction CT’s when pt symptomatic from it - determined by checking sat’s with CXR shows no pneumo compared to CXR with it • Define a pneumothorax that persists despite functioning CT’s in it that are on suction – as a “fixed pleural space deficit” - remaining lung will not expand fill it

  20. Air LeaksFramework

  21. Air LeaksManagement Persistent A/L • If A/L is still present on POD #3 or 4, pt otherwise ready discharge • Outpt. device past now use Atrium Express or Sahara mini-Express • Before use outpt. devices remove all CT except the one that has largest leak (best controls A/L) • Determined via “serial clamping”- usually the anterior apical CT

  22. Air LeaksManagement of Persistent A/L • Then place the outpt. device remaining CT • Watch pt for 24 hrs in hospital • Get CXR at 4 hrs and in AM • If no new pneumothorax, or if Pt is aSx with a new or larger pneumothorax and if no new subQ air, send pt home • Occurs 85% times / fails A/L > E-4

  23. Air LeaksManagement of Persistent A/L • If pt develops a symptomatic pneumothorax or new subQ air? • Return CT to seal or –10cm suction, (needed to alleviate problem). Try oupt device again 24 – 48 hrs. Ignore aSx pneumothoraces • Consider endobronchial valve • If problem occurs again, leave pt on pleuro-vac. Consider pleurodesis, doxycycline, talc if N2 or M1 to help lung stick

  24. Air LeaksManagement of Persistent A/L • Oupt. devices, Atrium and mini-Sahara valve are very successful • Allows most pt to be D/C home, allows us manage pt A/L as an out patient • Once home on outpt. device- WON • See these pt back in clinic 2-3 weeks • 90% pt A/L is gone

  25. Air LeaksRemoval of CT with Leak • If leak still present after home on outpt. device 2 weeks, now POD 3 • No longer have to admit them, do provocative CT clamping • Found that CT safely clamped, yes even if A/L • Pleural space loculated or compartmentalized from adhesions, able safely clamp CT in face A/L and remove it (evidence based) • Achieved goal sealed A/L, pt with no CT’s

  26. Air Leaks - FutureDigital Air Leak Digital air leak system Measures exact ml/hr of air leak, each breath

  27. Continuous A/L MonitoringConclusion • Continuous air leak systems that are digital are our future • More accurate, reproducible, provide medical record • Easy to use than the current (RDC) air leak classification system • Digital system provides air leak over 1, 3 and 6 hours, leads to safer and quicker chest tube removal and decreased hospital length of stay

  28. Continuous A/L MonitoringConclusion • Digivent and Thopaz - are few digital devises generates pressure curves in patients with air leak curves that may predict when a patient is developing a pneumothorax • May help avoid the need for a chest radiograph after chest tube setting changes • Decrease cost, decrease hospital stay, role yet fully undetermined

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