Scientific Letter
Outpatient management of persistent air leak
Tratamiento ambulatorio de la fuga aérea persistente
Sara Castillo-Acostaa,b,
, José Carlos Castillo-Acostaa,c, Pedro Miguel Rodríguez-Suárezb, Jesús María González-Martínd, Jorge Lorenzo Freixinet-Gilarta,b
Corresponding author
a Universidad de Las Palmas de Gran Canaria, Spain
b Servicio de Cirugía Torácica, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
c Servicio de Cirugía General y Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
d Unidad de Investigación, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
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array:2 [ "paginaInicial" => "722" "paginaFinal" => "723" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sara Castillo-Acosta, José Carlos Castillo-Acosta, Pedro Miguel Rodríguez-Suárez, Jesús María González-Martín, Jorge Lorenzo Freixinet-Gilart" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Sara" "apellidos" => "Castillo-Acosta" "email" => array:2 [ 0 => "scastilloaco@gmail.com" 1 => "scasaco@gobiernodecanarias.org" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0005" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "José Carlos" "apellidos" => "Castillo-Acosta" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0020" ] 1 => array:2 [ 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=> "Servicio de Cirugía Torácica, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain" "etiqueta" => "b" "identificador" => "aff0005" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía General y Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0010" ] 3 => array:3 [ "entidad" => "Unidad de Investigación, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain" "etiqueta" => "d" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento ambulatorio de la fuga aérea persistente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1251 "Ancho" => 1589 "Tamanyo" => 88967 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary history of patients with PAL.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">COPD: chronic obstructive pulmonary disease; PAL: persistent air leak.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Air leaks are a common problem in thoracic surgery and occur at a rate of 26%–54% on the first postoperative day. Postoperative persistent air leak (PAL) is defined as leak persisting after the third day after surgery according to Brunelli et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>, after the fourth day according to Cerfolio et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, and after the fifth day according to Varela et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">More than 50% of patients undergoing pleural drainage (PD) for pneumothorax develop air leaks at 48 h<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. The prevalence of PAL varies between 8% and 20%, and is more common in spontaneous secondary pneumothorax<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. Portable devices, such as the Heimlich valve (HV)<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>, are an accepted strategy in patients with high surgical risk<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. HV reduces drainage and hospitalization time<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to confirm the safety of HV in patients with postoperative PAL and pneumothorax and to determine its economic benefit.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We performed a descriptive study of a cohort of patients with PD and HV for PAL at hospital discharge between January 2013 and May 2020; the sample size was determined by this time period.</p><p id="par0025" class="elsevierStylePara elsevierViewall">For inclusion, patients had to have PAL after pneumothorax or surgery, they had to be stable, and they had to be independent or have good family support. Exclusion criteria were loss to follow-up, HVs in hospitalized patients, and devices used as a bridge to surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Patients were followed up on an outpatient basis with check-ups every 48–72 h, and PD was withdrawn after radiological revision 24 h after clamping.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main variables were success rate, proportion of patients with resolved PAL after HV placement, and cost saved per treatment. Epidemiological, clinical, and radiological variables were studied as independent variables.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Mean, standard deviation, and percentiles were calculated for quantitative variables, and frequency and percentages for qualitative variables. The Kolmogorov–Smirnov test was used to determine the normality of the data, the Mann–Whitney U test was used to compare the time distribution between 2 groups, and the Kruskall–Wallis test was used for more than 2 groups. Multiple linear regression with the genetic algorithm technique was used to obtain the most parsimonious model and the bootstrapping technique was used as a non-parametric method. Fisher’s exact test was used to determine the relationship between qualitative variables.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Mean age was 57 ± 17 years; 73% were men. Overall, 69% of PAL cases occurred after thoracic surgery, 34% of which were major pulmonary resections, and 48% were minor; 3% occurred after primary spontaneous pneumothorax, 26% after secondary pneumothorax, and 2% were iatrogenic, for a total of 105 cases in 98 patients.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Respiratory history of the series is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. Almost one third (30%) of patients had 1 previous event, 30% had 2, 14% had 3, 10% had 4, and 2% had 5.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Overall, 64% of the X-rays prior to HV placement showed an air pocket of less than 20% and 28% showed full expansion of the lung. After withdrawal of the PD and HV, 36% had an air pocket of less than 10%, 44% had lung expansion, and 9.5% had complete pneumothorax. PD was placed for a mean of 16 ± 8 days and HV for a mean of 7.5 ± 5.2 days.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Only 7% of patients had wound infection. Six patients were readmitted, 2 of which resolved when the drainage was connected to an aspiration system and 4 required a new PD (2 received antibiotics for pleural empyema). Another 8 patients were reoperated to resolve PAL. Accidental detachment of the PD occurred in 2 patients.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Since the cost of a room in the thoracic surgery ward in our center is €1453, we calculated a cost saving per treatment of €1,140,605 (785 days).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Multivariate analysis revealed that age, smoking, and tuberculosis were associated with longer PD duration, while smoking, pulmonary emphysema, and tuberculosis were associated with longer HV.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Few studies have been published on outpatient treatment with HV and these consist mainly of retrospective case series in patients with pneumothorax. Our sample size was larger than the mean reported in other studies in the literature (105 vs. a mean of 78.5 cases in the literature)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients with a history of tuberculosis had a longer duration of PD and longer time to resolution of PAL (p = 0.053). The association of tuberculosis with lung dysfunction and impaired gas exchange<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> has been described previously. These factors have been described as predictors of PAL<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10</span></a>, and are supported by the fact that a history of tuberculosis delays time to resolution of the air leak.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Approximately 90% of cases of PAL are resolved with conservative management and PD placement until air leak resolution<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>. However, the cost of healthcare increases<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> due to the extended hospital stay<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,12</span></a>. Wright et al. described PAL as the second cause of prolonged hospitalization in patients with lobectomy, after pain control<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>. Varela et al. estimated an excess cost of more than €39,000 for every 6 additional days of hospitalization in 21 patients with PAL<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our success rate was 82%, higher than the 77.9% observed in other studies (95% CI: 75.2%–80.4%)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>, regardless of etiology.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Alternatives for treating PAL include autologous blood patch pleurodesis<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and other agents<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>, although these are more invasive and involve potentially serious complications. Endobronchial valves are used in patients who are inoperable or who have failed on conservative treatment<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>, but these interventions are costly.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Surgery in postoperative PAL is reserved for large leaks and when conservative treatment fails. The technique varies depending on the existing lung damage (simple suture, resections, sealants).</p><p id="par0105" class="elsevierStylePara elsevierViewall">A larger sample size could reveal the influence of factors that have not yet been identified as significant. For this reason, it would be of interest to carry out prospective cooperative studies.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Devices such as HV for the outpatient treatment of PAL offer substantial cost savings for the healthcare system, and complications are minor. Implementation of this strategy may have clinical and economic benefits.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "⋆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Castillo-Acosta S, Castillo-Acosta JC, Rodríguez-Suárez P, González-Martín JM, Freixinet-Gilart JL. Tratamiento ambulatorio de la fuga aérea persistente. Arch Bronconeumol. 2021;57:722–723.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1251 "Ancho" => 1589 "Tamanyo" => 88967 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pulmonary history of patients with PAL.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">COPD: chronic obstructive pulmonary disease; PAL: persistent air leak.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Digital measurements of air leak flow and intrapleural pressures in the immediate postoperative period predict risk of prolonged air leak after pulmonary lobectomy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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