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Autologous blood-patch pleurodesis (ABPP) is a common technique used to manage patients with persistent pleural air leaks caused by pneumothorax. Other treatment options for persistent air leak (PAL) include chemical pleurodesis or placement of endobronchial valves, though severity of illness, risk of complications such as infection, or patient comorbidities may impact treatment decisions. The use of ABPP in patients with HIV and AIDS has not been reported in the literature. We present a case of a 32-year-old man with a history of AIDS (noncompliant with medications) and schizophrenia who presented with acute hypoxemic respiratory failure complicated by pneumothorax and PAL. He safely underwent ABPP without complications and eventually had resolution of PAL. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to determine whether prolonged air leak (PAL) is associated with postoperative morbidity and mortality following pulmonary resection after adjusting for differences in baseline characteristics using propensity score analysis. Summary background data: Patients with PAL after lung resection have worse outcomes than those without PAL. However, adverse postoperative outcomes may also be secondary to baseline risk factors, such as poor lung function. Methods: Patients who underwent pulmonary resection for lung cancer/nodules (1/2009-6/2014) were stratified by the presence of PAL [n = 183 with/1950 without; defined as >5 d postoperative air leak; n = 189 (8.3%)]; probability estimates for propensity for PAL from 31 pretreatment/intraoperative variables were generated. Inverse probability-of-treatment weights were applied and outcomes assessed with logistic regression. Results: Standardized bias between groups was significantly reduced after propensity weighting (mean = 0.18 before vs 0.08 after, P < 0.01). After propensity weighting, PAL was associated with increased odds of empyema (OR = 8.5; P < 0.001), requirement for additional chest tubes for pneumothorax (OR = 7.5; P < 0.001), blood transfusion (OR = 2; P = 0.03), pulmonary complications (OR = 4; P < 0.001), unexpected return to operating room (OR = 4; P < 0.001), and 30-day readmission (OR = 2; P = 0.009). Among other complications, odds of cardiac complications (P = 0.493), unexpected ICU admission (P = 0.156), and 30-day mortality (P = 0.270) did not differ. Length of hospital stay was prolonged (5.04 d relative effect, 95% confidence interval, 3.77-6.30; P < 0.001). Conclusions: Pulmonary complications, readmission, and delayed hospital discharge are directly attributable to having a PAL, whereas cardiac complications, unexpected admission to the ICU, and 30-day mortality are not after propensity score adjustment. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify risk factors for prolonged air leak (PAL) after pulmonary resection and summarize the quality of evidence. Summary Background Data: PAL frequently complicates recovery after pulmonary resection. Studies examining risk factors for PAL are highly variable in study population, design, and findings. Methods: We searched MEDLINE and EMBASE from database inception to December 31, 2017; studies reporting on risk factor (s) for PALafter pulmonary resection for malignant or benign pathology were included. Data on study characteristics, quality, and outcomes were extracted. Study quality and quality of evidence supporting risk factors were rated. Previous significance of risk factors was summarized. For the meta-analysis, pooled odd ratios or mean difference and I² heterogeneity were calculated using a random-effects model. Results: The systematic review included 37 studies, whereas 26 studies provided data for the meta-analysis, including 37,118 lung resections; 3546 had PAL occurrence. After meta-analysis, 17 risk factors were found to be significant; based on larger effect size, non-significant heterogeneity, and at least low quality of evidence or higher, the most strongly associated with PAL were forced expiratory volume in 1 second percent of predicted [mean difference = 8.84; 95% confidence interval (CI), 7.27-10.42], previous smoking history [odds ratio (OR) = 2.05; 95% CI, 1.63-2.58], major anatomic lung resection (OR = 2.82; 95% CI, 2.36-3.37), and pleural adhesions (OR = 1.94; 95% CI, 1.77-2.12). Modified GRADE quality of evidence was low or very low for the majority of risk factors. Conclusion: A large number of perioperative factors are associated with PAL. Our review can guide risk-reducing interventions, clinical prediction rules, and patient-specific treatment and management strategies for PAL. [ABSTRACT FROM AUTHOR]

Experience with autologous blood patch (ABP) pleurodesis for persistent air leak in the pediatric population is limited. The purpose of this series was to describe the experience with ABP at a single tertiary children's hospital. A retrospective study was performed of all thoracic procedures done by the pediatric surgery service over three years. Ten patients underwent a total of 17 ABPs. The median age of patients was 12 years (IQR 6–16). The most common underlying reasons for a thoracic procedure included: blebectomy for spontaneous pneumothorax (2), need for lung biopsy (2), resection of known malignant tumor (2), and empyema (2). The median number of days of persistent air leak before first ABP was 7.5 days (IQR 7–10). A second ABP was performed in 6 cases with a third procedure performed in one case. None of the patients developed respiratory compromise during ABP and no infectious complications were identified following ABP. Our cohort demonstrates that ABP for persistent air leak following thoracic surgery is effective with minimal morbidity in children. We believe ABP can be used early and in patients with a broad range of underlying lung pathology. [ABSTRACT FROM AUTHOR]

Abstract Introduction Bronchopleural fistula (BPF) is a feared complication of pulmonary resection. Fistula plugs (FP) have been described as an adequate treatment in anorectal disease. We describe our early experience placing an FP in the treatment of BPF. Materials and methods We retrospectively reviewed 5 patients for whom a FP was placed for BPF at our institution. Demographic data, initial perioperative information, method and technique of FP placement, and success is reported. Results Five patients (4 male, 1 female) with a median age of 63 years (range, 57–76 years) underwent 6 FP placements for BPF. Two patients were post-pneumonectomy and 3 patients post-lobectomy. The median time to presentation following surgery was 118 days (range 22–218). Upon bronchoscopic or operative re-evaluation, 3 patients had successful cessation of their air leak at 0, 1 and 4 days. Two of three patients subsequently underwent a thoracic muscle flap placement to augment healing. One patient had a persistent air leak despite 2 separate FP placements. The air leak stopped with endobronchial valves (EBV) which were deployed proximal to the FP, 9 days after placement of the FP. Another patient had a successful muscle flap placed 80 days after FP placement. There were no complications associated with the FP. Three of five patients were deemed successfully treated with FP placement alone. Conclusion In patients with a postoperative BPF and pleural window, placement of a FP had a modest success rate and can be considered as a treatment modality option for BPF. [ABSTRACT FROM AUTHOR]

Abstract Spontaneous pneumothorax is a rare complication of pneumocystis jirovecii pneumonia. We report a patient with pneumocystis jirovecii pneumonia and therapy-refractory, right-sided pneumothorax due to persistent air leak (PAL) despite prolonged chest tube placement and multiple pleurodesis attempts. Due to the patient's morbidity, we evaluated if the PAL can be sealed by unidirectional endobronchial valves (EBVs). After occlusion of the right upper lobe by a balloon catheter, the air leak flow-rate decreased from 800 ml/min to 250 ml/min. Zephyr EBVs (ZEBVs) were placed in the segmental right upper lobe bronchi and subsequently, a complete resolution of the pneumothorax was noted. During 30 months of follow-up, neither recurrence of pneumothorax nor any adverse events of EBV treatment were noted. We conclude that ZEBV placement might be an effective and well-tolerated treatment option for PAL secondary to pneumocystis jirovecii pneumonia with promising long-term results. [ABSTRACT FROM AUTHOR]

Patients with severe COVID-19 Pneumonia requiring prolonged mechanical ventilation have an increased incidence of pneumothorax. Mechanically ventilated patients who are critically ill and develop a persistent air leak from pneumothorax are poor candidates for surgical repair. As the persistent air leak can be a significant barrier to vent-weaning and clinical stability, these patients present a unique clinical challenge. A 65-year-old male intubated and on prolonged mechanical ventilation for severe COVID-19 Pneumonia developed a pneumothorax complicated by a persistent alveolar-pleural fistula with a persistent air-leak. Given his critical state with ongoing pressor requirements and elevated vent requirements, surgical repair was not an option. A bedside bronchoscopy occlusion study with isolation of the air leak, and subsequent autologous endobronchial blood-patch repair with thrombin was performed with rapid and definitive resolution of the air leak. The patient progressed favorably, ultimately being weaned from the ventilator, decannulated, and walking out of the hospital. In critically ill ventilated patients with pneumothorax complicated by a persistent air-leak, bedside endobronchial evaluation and blood-patch repair is a feasible approach to management. [ABSTRACT FROM AUTHOR]

Pneumothorax is a serious but common complication in patients with cystic fibrosis (CF). It has adverse prognostic implications as well as associations with subsequent reduction in lung function and significant risk of recurrence. Management dilemmas frequently occur that are beyond current guidelines. We review the evidence and highlight management difficulties in pneumothoraces in CF. [ABSTRACT FROM AUTHOR]

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Abstract: Purpose: Persistent air leak (PAL) is associated with increased morbidity. Standard treatment of PAL includes chemical or mechanical pleurodesis. Long-term impact of these interventions is not known in the pediatric population. Autologous blood patch (ABP) offers a novel treatment option. We report our experience with autologous blood patch to successfully treat PAL in eight children. Methods: Children with PAL were treated with ABP. A fresh whole blood sample was obtained from each patient and injected via their pre-existing chest tube. Volume of blood injected, time to cessation of air leak, time to chest tube removal, outcomes and complications were reviewed. Results: Eight children aged 2 months to 18 years underwent ABP. Three children had immediate seal of air leak, while two patients sealed after 1 and 2 days. Three patients required a second ABP, after which they had immediate seal of air leak. Chest tubes were removed within 2–3 days in 7 cases. One child developed an asymptomatic pneumothorax and required 8 days for radiographic resolution. Conclusion: ABP appears to be a safe and effective treatment option for PAL in children. ABP offers an inexpensive, easy to perform technique and avoids use of toxic chemicals for pleurodesis in pediatric patients. [Copyright &y& Elsevier]

In this case report we present a 5-year old boy with a bronchopleural fistula with persistent air leak following complicated empyema. Treatment with antibiotics and pleural drainage did not stop the air leak and consequently prolonged drainage of the pleural cavity was needed. As this would account for weeks of hospitalization, we decided together with the parents, following the main principles of Patient-and-Family Centered Care, to treat the child at home with the use of a Heimlich valve. A Heimlich valve may be an old-fashioned, but effective one-way-valve permitting evacuation of air and fluid from the thoracic cavity without the need of high technology solutions and with minimal risk to the patient. This may prevent prolonged hospitalization, increase quality of life of the patient and save medical costs. After 2 months the chest tube with Heimlich valve was successfully removed. Recovery was uneventful; long term follow up showed restricted lung function with a total lung capacity of around 78% and fibrotic changes of the right upper lobe on chest CT scan. [ABSTRACT FROM AUTHOR]

The indications and utility of flexible bronchoscopy have expanded over the past few decades with major innovations in design and development of new tools for endobronchial interventions and image-guided tissue sampling techniques. This review highlights the application of advanced diagnostic bronchoscopy (including endobronchial ultrasound and CT navigational techniques), cryotherapy and the use of one-way endobronchial valves for persistent air leak in the pediatric setting. [ABSTRACT FROM AUTHOR]

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree. Herein, we report a patient with persistent air leak after necrotizing pneumonia, where tract of BPF was not apparent in computed tomography (CT). Despite control of infection, watchful observation, repetitive procedures, and surgery, air leak was not resolved. This led to consideration of the endobronchial valve (EBV) placement. After identifying the bronchial segment leading to the fistula with indigo carmine, precise occlusion of the lingular division of the left upper lobe (LUL) was performed using an EBV. Subsequently, the air leak was resolved. During 6 months of follow-up, neither recurrence of BPF nor any procedure-related complications were noted. We concluded that precise EBV placement by identifying bronchial segment leading to the BPF, could be an effective treatment for persistent air leak. [ABSTRACT FROM AUTHOR]

Surgery to address parenchymal lung disease in children is rare. One of the complications of the surgery is a persistent air leak (PAL). Intrabronchial valves (IBV), which received FDA approval for treating PAL in recent years, limit or exclude the inflow of air towards the pleura and allow air and secretions to flow towards central airways. The valves have been effective in adults with PAL but little has been published on their use in children. Retrospective chart review was performed after IRB approval on patients treated with IBV after surgical excision of lung parenchyma. A literature review was then performed. 2 pediatric patients are presented. Patient 1, a 10 year old girl underwent excision of a lung mass that developed persistent air leak. Traditional conservative methods did not seal the air leak for 23 days but an IBV sealed the leak in 24 h. Patient 2, a 6 year old boy underwent a pneumonectomy with post-operative bronhical leak. The bronchus was repaired but a leak persisted for 36 days. An IBV sealed the leak immediately. Intrabronchial valves can be used for the management of persistent pulmonary air leaks. We propose a tentative algorithm for using the devices in children with PAL. [ABSTRACT FROM AUTHOR]

The development of a persistent air leak after pneumothorax can be encountered in patients with underlying structural lung disease. In those with advanced malignancy or other comorbidities, the ability to tolerate general anesthesia and thoracoscopic procedures may limit definitive management. We describe the case of a 68-y-old male with refractory acute myelogenous leukemia presenting with recurrent secondary spontaneous pneumothorax and persistent air leak related to an underlying fungal pneumonia. Endobronchial valve placement allowed for timely chest tube removal and discharge from the hospital, as well as avoidance of a thoracoscopic procedure and pleurodesis. [ABSTRACT FROM AUTHOR]

Objective Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables. Methods Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed. Results A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk. Conclusions Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management. [ABSTRACT FROM AUTHOR]