Table 2. Comparative table of post-operative measures to manage prolonged air leak.
| Author, year | Used method | Study design | Groups | Number of patients | Mean AL/chest drain/LOS duration | Morbidity/mortality | Type of lung resection | Conclusions/notes |
|---|---|---|---|---|---|---|---|---|
| Autologous blood patch | ||||||||
| Shackclot, 2006 (37) | Autologous blood patch | RCT | ABP vs. no ABP | 10 vs. 10 | POAL: 5 vs. 11 days (P<0.001); Chest drain: 6.5 vs. 12 days (P<0.001); LOS: 8 vs. 13.5 days (P<0.001) | 1 patient (10%) in the study group developed empyema on 7th POD, successfully treated by drainage and antibiotics | Lobectomy: 10 vs. 10 | The two groups are comparable for smoking habit (P=1.0) and presence of underlying lung disease (P=1.0); ABP can be repeated every 48 h until the AL stops; after ABP, the AL was sealed by the next day in 58.6% of treatments; ABP is effective in sealing AL after lobectomy |
| Andreetti, 2007 (38) | Autologous blood patch | RCT | A: 50 mL, B: 100 mL, C: no ABP | A: 12, B: 13, C: 15 | POAL: 2.3 vs. 1.5 vs. 6.3 days (p<0.05) | None | Lobectomy: 12 vs. 13 | Mean FEV1: 2.5 vs. 2.4 vs. 2.3 L; 100% success rate. No costs |
| Campisi, 2021 (39) | Autologous blood patch | Retrospective multicentric | A= ABP for POAL >5 days; B= observation | 109 vs. 109 | Chest drain: 8.12 vs. 9.30 days (P=0.004) LOS: 10 vs. 11 (P=0.045) | No ABP-related adverse events | Lobectomy:109 vs. 109 | The two groups are comparable for smoking habit (P=0.491) and COPD prevalence (P=0.278). Those variables are not associated to chest removal timing at univariate analysis; ABP is associated with fewer postoperative complications (6 vs. 17, P=0.015) and need for reoperation (0 vs. 4, P=0.044); 120 mL of blood are better than 60 mL |
| Hasan, 2021 (40) | Autologous blood patch | Retrospective | ABP (90 mL) vs. no ABP for POAL >5 days | 34 vs. 76 | Chest drain: 11 vs. 16 days (P=0.14); LOS (P=0.13) | No differences. Empyema < in ABP group | Wedge resection: 9 vs. 18; segmentectomy: 1 vs. 7; lobectomy: 18 vs. 44; combined: 6 vs. 7 | No significant differences between the two groups in terms of FEV1 (P=0.17) and smoking history (P=0.88); ABP is associated with a lower readmission rate (P=0.02) and reoperation (P=0.05); ABP patients are less likely to be discharged with a chest tube |
| Chemical pleurodesis | ||||||||
| Liberman, 2010 (4) | Chemical pleurodesis by talc, bleomycin, doxycycline, minocycline | Retrospective | Observation vs. pleurodesis | 33 vs. 41 | POAL: 10.7 days (all cohort); in patients underwent pleurodesis, AL ceased after a mean of 2.8 days after the procedure | No adverse event related to pleurodesis. One patient in the pleurodesis cohort developed empyema | Lobectomy: 69; bilobectomy: 5 | Differences between respiratory function tests parameters and respiratory comorbidities are not reported; pleurodesis successful in 40 of 41 patients (97.6%), 5 patients required repeated sclerosis; chemical pleurodesis is a simple, effective, and a rapid method of treating prolonged air leak after pulmonary resection |
| Jabłoński, 2018 (41) | Chemical pleurodesis by Iodine or Doxycycline | RCT | Iodine group; doxycycline group; drainage alone group | 30 vs. 34 vs. 35 | Chest drain: 9.23 vs. 11.5 vs. 13.09 days (P<0.0001); LOS: 12.67 vs. 16.5 vs. 15.89 days (significantly better in Iodine group) | No differences between the three groups. Few allergic reactions to doxycycline (1 patient) and Iodine (2 patients) | Wedge resection: 3 vs. 4 vs. 5; segmentectomy: 1 vs. 2 vs. 1; lobectomy: 24 vs. 25 vs. 26; sleeve lobectomy: 1 vs. 0 vs. 1; lower bilobectomy: 1 vs. 2 vs. 1; upper bilobectomy: 0 vs. 1 vs. 1 | Data on respiratory function tests parameters and respiratory comorbidities are not reported; pleurodesis was performed in the 6th, 7th and 8th POD in patients with PAL; PNX recurrence rate is similar between the three groups (P=0.42); iodine pleurodesis showed favorable results compared with Doxycycline pleurodesis or drainage alone |
| Chaari, 2021 (42) | Chemical pleurodesis by povidone iodine for PAL | RCT | A: povidone iodine; B: no povidone iodine | 19 vs. 21 | Chest drain: 9.21 vs. 15.62 days (P=0.001); LOS: 11.05 vs. 18.9 days (P<0.0001) | 21% (4 patients) vs. 19% (4 patients); povidone iodine-related adverse events (Group A): mild fever, chest pain, bad taste sensation; Group B: lung atelectasis, wound infection, respiratory distress, pleural empyema | Lobectomy 4 vs. 6; segmentectomy 1 vs. 0; wedge resection: 2 vs. 1 | Group A and B are similar in terms of respiratory diseases prevalence (emphysema and COPD) and smoking habit; mean number of injections per patient: 2.11; no recurrence of PNX in Group A (effectiveness: 100%), 1 in Group B (4.76%); the study includes also patients underwent bullectomy and/or pleurodesis (10 vs. 9), lung decortication (3 vs. 6) and surgery for hydatid cyst (1 vs. 3) |
| Chest drain management | ||||||||
| Brunelli, 2004 (43) | Suction | RCT | Suction −20 cmH2O vs. water seal | 73 vs. 72 | POAL: 6.1 vs. 8.0 days (P=0.9); chest drain: 10.0 vs. 12.5 days (P=0.9); LOS: 10.9 vs. 11.3 (P=0.9) | 17.8% vs. 31.9% (P=0.056). Water seal group had higher incidence of pneumonia and arrhythmia | Lobectomy: 73 vs. 72 | The two groups are comparable in terms of respiratory function tests parameters, smoking habit and pleural adhesions prevalence; incidence of PAL: 30.1% vs. 27.8% (P=0.8); no significant differences even when corrected for length of stapled parenchyma and site of resection; authors routinely perform pleural tenting in upper lobectomies/bilobectomies |
| Alphonso, 2005 (44) | Suction | RCT | Suction vs. no suction | 116 vs. 123 | AL for more than 6 days: 7.8% vs. 10.1% | Recurrent PNX: 2 cases vs. 3 cases | Wedge resection: 18 vs. 19; lobectomy: 55 vs. 56; lung biopsy: 10 vs. 11 | In both groups there were current (42 vs. 49) and ex-smokers (50 vs. 55). No data on respiratory function tests or lung diseases’ prevalence are available; no differences between the two groups in terms of persistence of AL (P=0.62); authors are in favor of no-suction policy; study comprehends also patients underwent surgical pleurodesis for pneumothorax (33 vs. 37) and lung biopsies (10 vs. 11) |
| Brunelli, 2005 (45) | Alternative suction | RCT | Water seal vs. alternate suction | 47 vs. 47 | POAL: 4.2 vs. 3.1 days (P=0.3); chest drain: 8.6 vs. 6.2 days (P=0.002); LOS 10.4 vs. 8 days (P=0.004) | No differences between the two groups | Lobectomy: 47 vs. 47 | The two groups are comparable in terms of respiratory function tests parameters, smoking habit and pleural adhesions prevalence; alternate suction patients showed a reduced incidence of POAL >4 days (P=0.04) and >7 days (P=0.02); suction applied overnight allows early mobilization of patients |
| Brunelli, 2013 (46) | Suction | RCT | Group 1: regulated individualized suction (range: −11 to −20 cmH2O, according to lobectomy type); Group 2: regulated seal (−2 cmH2O) | 50 vs. 50 | POAL: 28 vs. 22.2 h (P=0.6) in the whole cohort; between those having POAL immediately after extubation, patients of Group 2 had an air leak lasting 34.5 h less than those of Group 1 (52.9 vs. 87.4 h, P=0.07) | No differences between the two groups | Lobectomy: 50 vs. 50 | Group 1 patients have significantly higher mean Tiffeneau Index value if compared to Group 2 (0.74 vs. 0.69, P=0.006); nevertheless, other respiratory function test parameters are comparable between the two groups, as well as the prevalence of pleural adhesions; PAL incidence: 5 vs. 4 patients (P=0.7); the regulated seal mode had the same effect as the regulated suction one; patients with immediate POAL managed with regulated seal showed a trend towards a shorter duration of air leak |
| Holbek, 2019 (47) | Suction | RCT | −2 vs. −10 cmH2O | 111 vs. 111 | Chest drain: 27.4 vs. 47.5 h (P=0.047); LOS: 2 vs. 3 days (P=0.18) | No differences in the proportion or the size of the PNX or subcutaneous emphysema after drain removal, nor in postoperative morbidity | Lobectomy: 111 vs. 111 | Mean FEV1: 87.1% of expected vs. 87.4%; mean Tiffeneau Index value: 68% of expected vs. 71.3%; current or ex-smoker status: 103 vs. 97; COPD prevalence: 57 patients vs. 48; previous ipsilateral surgery: 12 patients vs. 6; incidence of PAL >5 days: 14.4% vs. 24.3% (P=0.089); a low suction level significantly shortened time to air leak cessation and total fluid production |
| Mitsui, 2021 (48) | Suction | Retrospective | A (−5 cmH2O); B (−10 cmH2O); C (−20 cmH2O) | 49 vs. 100 vs. 68 | POAL: 0.57 days A, 0.78 days B, 1.13 days C (P=0.019; P=0.010 for anatomical resections only) | Not reported | Wedge resection:20 vs. 53 vs. 34; segmentectomy: 4 vs. 17 vs. 4; lobectomy: 25 vs. 30 vs. 30 | Study included also patients who underwent surgery for PNX; patients with emphysema/interstitial pneumoniae: 8/2 vs. 9/4 vs. 7/2; IOAL: 45% A, 36% B, 29% C; POAL: 16% A, 24% B, 35% C; low-pressure suction after pulmonary resection seems to avoid or promptly improve postoperative air leaks |
| Digital drainage systems | ||||||||
| Filosso, 2015 (49) | Digital drainage | RCT | DDs vs. TDs | 40 vs. 40 | Chest tube: 3 vs. 5 days (P=0.0009); LOS: 7 vs. 8 days (P=0.0385) | Not reported. | Wedge/segmentectomy: 6 vs. 8; lobectomy 32 vs. 31; bilobectomy: 2 vs. 1 | FEV1 <80% of expected: 10 vs. 10 patients (P=1). Smokers: 24 vs. 25 (P=0.818); TDs were connected to wall suction; DDs were settled to maintain a constant negative pressure; DDs reduce the interobserver variability on AL quantification and allow early patient mobilization |
| Gilbert, 2015 (50) | Digital drainage | RCT | DDs vs. TDs | 43 vs. 42 | LOS: 6 vs. 6 days (P=0.36)Chest tube: 4.9 vs. 5.6 days (P=0.11) | Chest tube reinsertions occurred only in patients randomized to TDs | Lobectomy: 31 vs. 37 | The two groups are comparable in terms of comorbidities, lung diseases prevalence, smoking habit, pleural adhesions and intraoperative use of sealants; clamping trials: 23% vs. 50% (P=0.01): digital technology can alter chest tube management by significantly reducing clamping trials before removal of the chest tube |
| Mendogni, 2021 (51) | Digital drainage | Multicentric RCT | DDs vs. TDs | 94 vs. 115 | Chest tube: 2.4 vs. 3.8 days (P=0.203); difference between LOS and chest tube duration: 1.3 vs. 1.4 days (P=0.999) | No differences between the two groups | Lobectomy: 94 vs. 115 | Interim analysis of RCT’s preliminary data; COPD: 15 vs. 12 patients (P=0.17). Asthma: 3 vs. 3 patients (P=0.04). Respiratory function test values are comparable in the two groups; incidence of PAL: 1.1% vs. 2.6% (P=0.999); presence of AL in the 1st POD predicts the prolonged chest tube requirement |
ABP, autologous blood patch; AL, air leak; BPF, broncho-pleural fistula; COPD, chronic obstructive pulmonary disease; DD, digital drainage; FEV1, forced expiratory volume in 1 second; IOAL, intra-operative air leak; LOS, length of stay; PAL, prolonged air leak (>5 days); PN, phrenic nerve; PNX, pneumothorax; POAL, post-operative air leak; POD, post-operative day; RCT, randomized controlled trial; ST, standard treatment; TD, traditional drainage.