Treatment strategy in patients in the prolonged air leak cohort was surgeon dependent and often based on volume of air leak. The retrospective nature of data acquisition introduces several biases into our analysis. We acknowledge limitations in our study design. Removal of chest tubes at 2 to 3 weeks despite the presence of persistent air leak after pulmonary resection has been recently proposed by a single institution as an option with few complications [ The disadvantages to the Heimlich strategy compared with pleurodesis include the inconvenience of discharging patients with a chest tube in place (often requiring home care services and supplies for site care), chest tube-related discomfort and pain, risk of pleural infection secondary to indwelling chest tube, and the inconvenience of bringing patients back to the hospital for frequent visits and X-rays until the leak seals. Advantages to the Heimlich valve strategy include its ease of placement, immediate patient discharge from hospital, and lack of foreign substance instillation into the pleural cavity with its inherent risks. The major contender in the treatment of prolonged air leak after pulmonary resection is patient discharge with a Heimlich valve or a mini-chest tube collection system with a one-way valve in place. Success of pleurodesis was measured by resolution of air leak and removal of chest drain before discharge from the hospital. More commonly, 5 grams of sterile talc was used as the sclerosant of choice in most patients. Multiple sclerosing agents were used independently throughout the study period including talc, bleomycin, doxycycline, and minocycline. After 1 to 2 hours, the pleurovac tubing is placed back on the floor and low level suction (10 to 20 cm H 2O) is applied for 48 hours to potentiate apposition of visceral and parietal pleura. The patient was instructed to turn from side to side every 15 minutes to facilitate uniform intrapleural application of the agent. Patients' chest tubes were first evaluated on water seal to ensure the absence of any significant lung collapse prior to attempting bedside pleurodesis. The sclerosant was administered in a sterile manner into the chest tube to avoid empyema. In order to perform pleurodesis for the treatment of prolonged air leaks after pulmonary resection, a pleural sclerosing agent was sterilely instilled through the indwelling chest tube, and then the Pleur-evac (Teleflex Medical, Research Triangle Park, NC) flexible tubing was raised above the patient's bed for 1 to 2 hours. This study was approved by the Institutional Review Board (IRB) at the Massachusetts General Hospital and individual consent was waived. Persistent air leaks were defined as those patients with ongoing air leak after the fifth postoperative day, as well as patients undergoing an intervention for a large volume air leak prior to day six. Both water seal and suction (20 cm H 2O) were used postoperatively depending on surgeon preference. Most surgeons placed one or two 28Fr chest tubes after lobectomy. Intraoperative and postoperative management of chest tubes were similar among eight thoracic surgeons. All patients underwent resection and received all of their postoperative care at a single institution. Exclusion criteria consisted of the following: all video-assisted pulmonary resections wedge resections segmentectomies and pneumonectomies. This study consists of a retrospective case-control study examining all isolated lobectomies and bilobectomies performed by thoracotomy at a single institution. PAL was associated with increased length of stay (14.2 vs 7.1 days, p < 0.001) and time with chest tube (11.5 vs 3.4 days, p < 0.001). Postoperative pneumonia occurred with increased frequency in PAL patients (6 of 45 vs 34 of 700, p = 0.014). Mean time to treatment was 8.4 ± 3.6 days, mean duration of air leak was 10.7 ± 4.5, and mean duration of air leak postsclerotherapy was 2.8 ± 2.2 days. Sclerosis was successful in 40 of 41 patients (97.6%). One patient required a muscle flap, one readmission for pneumothorax, and one empyema resulting in death. Seventy-three patients (93.6%) required no further intervention. Treatment of PAL consisted of observation (n = 33, 42.3%), pleurodesis (n = 41, 52.6%), Heimlich valve (n = 3, 3.8%), and reoperation (n = 1, 1.3%). Univariate analysis demonstrated that female gender, smoking history, and forced vital capacity were predictive risk factors. Propensity score analysis matching case and controls showed no predictive risk factors for air leak using a logistic regression model. Controls consisted of 700 consecutive patients. Over 9 years, 78 PALs were identified in 1,393 patients (5.6%).
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