Management of spontaneous pneumothorax: a mini-review on its latest evidence.

Spontaneous pneumothorax usually presents as a medical emergency and requires prompt attention and treatment. In patients with underlying lung diseases, it is often associated with prolonged hospitalization, persistent air leak and also a high rate of recurrence. It brings considerable clinical burden to patients and therefore advancement of spontaneous pneumothorax management is eagerly anticipated. In recent years, conservative approach with avoidance of invasive treatment has risen to be a main consideration for primary spontaneous pneumothorax (PSP) patients who are clinically stable with minimal symptoms. The body of evidence in secondary spontaneous pneumothorax (SSP) group is less robust compared with that in PSP group. Non-surgical treatment in SSP is becoming more common due to concerns about morbidity and mortality after surgical pleurodesis as patients are usually older with more underlying medical diseases. Until last year, there have been no updates on the international recommendation of pneumothorax management since the British Thoracic Society (BTS) guideline published in 2010. The latest 2023 BTS guideline on pleural diseases provides us a good opportunity to review the latest development and literature of the care for patients with spontaneous pneumothorax. This article will explore the goals of pneumothorax treatment including air evacuation, cessation of persistent air leak and prevention of recurrence.

Bronchoscopic management in persistent air leak: a narrative review.

Background and Objective: Persistent air leak (PAL) represents a challenging medical condition characterized by prolonged air leak from the lung parenchyma into the pleural cavity, often associated with alveolar-pleural fistula or bronchopleural fistula (BPF). The objective of this narrative review is to explore the causes, clinical implications, and the evolving landscape of bronchoscopic treatment options for PAL. Methods: The literature search for this review was conducted using databases such as PubMed/MEDLINE, and Scopus databases. Articles published from inception until 28th August, 2023, focusing on studies that discussed the causes, diagnosis, and management strategies for PAL were included. Keywords included bronchoscopic management, bronchopleural fistula, endobronchial valve, sealant, blood patch pleurodesis, spigot, air leak, PAL, management, comparative study. Key Content and Findings: PAL commonly arises from secondary spontaneous pneumothorax, necrotizing pneumonia, barotrauma induced by mechanical ventilation, chest trauma, or postoperative complications. Understanding the underlying etiology is crucial for tailoring effective management strategies. While conventional intercostal drainage resolves the majority of pneumothorax cases, PAL is diagnosed when the air leak persists beyond 5 to 7 days. Prolonged PAL can lead to worsening pneumothorax, respiratory distress, and increased morbidity. Early identification and intervention are essential to prevent complications. Conservative approaches involve close monitoring and supplemental oxygen therapy. These strategies aim to promote natural healing and resolution of the air leak without invasive interventions. Bronchoscopic techniques, such as endobronchial valves (EBVs), sealants, and autologous blood patch (ABP), have emerged as promising alternatives for refractory PAL. These interventions offer a targeted and minimally invasive approach to seal the fistulous connection, promoting faster recovery and reducing the need for surgical interventions. Conclusions: PAL is a clinical challenge, and their management requires a tailored approach based on the underlying cause and severity. Bronchoscopic interventions have shown efficacy in cases of refractory PAL. Early recognition, multidisciplinary collaboration, and a personalized treatment plan are essential for optimizing outcomes in patients with PAL.

Advanced Diagnostic and Therapeutic Bronchoscopy in Pediatrics.

Advanced diagnostic and therapeutic flexible bronchoscopy in children is a rapidly evolving field. Recent advances in technology and awareness of indications, risks, and benefits by pediatric providers have greatly increased the use of advanced techniques in children. This review highlights advanced diagnostic procedures including assessment of endobronchial lesions, mediastinal/hilar masses, and peripheral lung nodules as well as therapeutic techniques for restoring airway lumen patency, managing persistent air leaks, and treating tracheoesophageal fistulas in children as well as the potential to spare these patients more invasive procedures.

Bronchopleural fistula management in a pediatric patient requiring extracorporeal membrane oxygenation.

Bronchopleural fistula (BPF) is a connection between the bronchus and pleural cavity. It is associated with high morbidity and mortality and management of BPF has not been well described in the pediatric population. We describe a 2-year-old girl who presented with fever and increased work of breathing, found to have atypical hemolytic uremic syndrome and Streptococcus necrotizing pneumonia with development of persistent air leak due to bronchopleural fistulas requiring extracorporeal membrane oxygenation (ECMO). Three endobronchial valves were placed with successful resolution of bronchopleural fistulas. She required tracheostomy for chronic respiratory failure and endobronchial valves were eventually removed. Approximately 3.5 months after discharge to acute care rehabilitation, tracheostomy was successfully decannulated. This case highlights the successful use of endobronchial valves for resolution of BPF while on ECMO as well as the importance of further studies on optimal candidates, timing and duration of intervention in addition to sequelae of endobronchial valve placement.

Endobronchial Valves in Treatment of Persistent Air Leak: European Case-Series Study and Best Practice Recommendations - From an Expert Panel.

INTRODUCTION: Persistent air leak (PAL) is associated with prolonged hospitalization, high morbidity and increased treatment costs. Conservative treatment consists of observation, chest tube drainage, and pleurodesis. Guidelines recommend surgical evaluation if air leak does not respond after 3-5 days. One-way endobronchial valves (EBV) have been proposed as a treatment option for patients with PAL in which surgical treatment is not feasible, high risk or has failed. We aimed to provide a comprehensive overview of reported EBV use for PAL and issue best practice recommendations based on multicenter experience. METHODS: We conducted a retrospective observational case-series study at four different European academic hospitals and provided best practice recommendations based on our experience. A systematic literature review was performed to summarize the current knowledge on EBV in PAL. RESULTS: We enrolled 66 patients, male (66.7%), median age 59.5 years. The most common underlying lung disease was chronic obstructive pulmonary disease (39.4%) and lung cancer (33.3%). The median time between pneumothorax and valve placement was 24.5 days (interquartile range: 14.0-54.3). Air leak resolved in 40/66 patients (60.6%) within 30 days after EBV treatment. Concerning safety outcome, no procedure-related mortality was reported and complication rate was low (6.1%). Five patients (7.6%) died in the first 30 days after intervention. CONCLUSION: EBV placement is a treatment option in patients with PAL. In this multicenter case-series of high-risk patients not eligible for lung surgery, we show that EBV placement resulted in air leak resolution in 6 out of 10 patients with a low complication rate. Considering the minimally invasive nature of EBV to treat PAL as opposed to surgery, further research should investigate if EBV treatment should be expanded in low to intermediate risk PAL patients.

Resolving persistent air leaks associated with autosomal dominant hyper-IgE syndrome using one-way endobronchial valves: report of cases.

Background: Autosomal dominant hyper-IgE syndrome (AD-HIES) is a rare genetic syndrome that alters typical post-operative wound healing. AD-HIES patients are prone to develop persistent air leaks (PALs) due to bronchopleural fistulas. This report is unique in that it describes a novel approach to managing PALs in this complex population. Case Description: Two patients with AD-HIES were identified in the setting of a PAL. The first patient was a 31-year-old male with recurrent pneumonia, who developed a large hydropneumothorax following re-presentation with fever and cough. A chest tube was inserted, which required continuous suction in the setting of what developed into a PAL. Subsequently, an endobronchial valve (EBV) was deployed to successfully manage the PAL. The second patient was a 25-year-old male, who developed a post-operative large volume air leak following a complicated surgical resection of a giant pneumatocele. Several attempts of placing multiple EBVs were required to finally address the PAL. In both cases, EBVs were successfully employed to manage and eventually resolve symptoms caused by PAL. Conclusions: Our experience suggests that EBVs are successful in treating PAL in the setting of AD-HIES, which often manifests as highly complex scenarios. Hence, EBVs represent a valuable addition to the therapeutic armamentarium against recalcitrant PAL. EBVs were well-tolerated in patients afflicted by AD-HIES, with no progressive infections noted. Both patients ultimately were able to resolve their PAL following placement of the EBV.

Persistent Air Leak Due to Chest Drain Malposition.

Persistent or prolonged air leak (PAL) is one of the common complications that may happen after many procedures in thoracic surgery. The treatment may change based on the cause, and accordingly, the understanding and awareness of the causes and the exclusion of the rare causes are very important in the treatment of this condition. Here, we present an unusual case with PAL due to chest drain malposition with intraparenchymal insertion in an elderly patient who presented initially with a secondary spontaneous pneumothorax (SSP).

Evaluation and management of persistent air leak.

INTRODUCTION: Persistent air leaks (PAL) represent a challenging clinical problem for which there is not a clear consensus to guide optimal management. PAL is associated with significant morbidity, mortality, and increased length of hospital stay. There are a variety of surgical and non-surgical management options available. AREAS COVERED: This narrative review describes the current evidence for PAL management including surgical approach, autologous blood patch pleurodesis, chemical pleurodesis, endobronchial valves, and one-way valves. Additionally, emerging topics such as drainage-dependent air leak and intensive care unit management are described. EXPERT OPINION: There has been considerable progress in understanding the pathophysiology of PAL and growing evidence to support the various non-surgical treatment modalities. Increased recognition of drainage-dependent persistent air leaks offers the opportunity to decrease the number of patients requiring additional invasive treatment. Randomized control trials are needed to guide optimal management.

Hydropneumothorax With Bronchopleural Fistula Following the Activation of Mycobacterium tuberculosis: A Case Report.

Tuberculosis is not a disease of the current era; failure to eradicate it continues to cause unusual complications, which results in detrimental sequelae to the patients. It usually presents with respiratory symptoms such as shortness of breath, cough, and fever, in addition to extrapulmonary symptoms. While there have been a few published case reports on patients presenting with hydropneumothorax due to tuberculosis, its occurrence is relatively rare. Furthermore, to the best of our knowledge, this is the first published case of hydropneumothorax due to tuberculosis within the United Arab Emirates, as confirmed by a search on PubMed. Here, we present a case of a young farmer from Bangladesh who presented with shortness of breath and fever and was found to have decreased air entry along with hyperresonance sounds on examination. Fortunately, the patient was in a stable state, required minimum oxygen therapy, and was not escalated for further noninvasive or invasive mechanical ventilation. The patient was admitted to a tertiary hospital to receive initial medical therapy interim to transfer the patient to a facility where thoracic surgeons are found.

From plugging air leaks to reducing lung volume: a review of the many uses of endobronchial valves.

INTRODUCTION: One-way endobronchial valve treatment improves lung function, exercise capacity, and quality of live in patients with severe emphysema and hyperinflation. Other areas of therapeutic application include treatment of persistent air leak (PAL), giant emphysematous bullae, native lung hyperinflation, hemoptysis, and tuberculosis. AREAS COVERED: In this review, we will assess the clinical evidence and safety of the different applications of one-way endobronchial valves (EBV). EXPERT OPINION: There is solid clinical evidence for the use of one-way EBV for lung volume reduction in emphysema. Treatment with one-way EBV can be considered for the treatment of PAL. The application of one-way EBV for giant bullae, post lung transplant native lung hyperinflation, hemoptysis, and tuberculosis is under investigation and more research is required to investigate the efficacy and safety of these applications.

A customized multimodality approach for prolonged air leaks (PAL) in mechanically ventilated patients.

ARDS in general and severe COVID ARDS (CARDS) is particularly associated with high rates of barotrauma. Two cases with severe CARDS developed bilateral pneumothorax with persistent air leak (PAL). Conservative management with prolonged chest tube drainage did not help in PAL resolution and both patients continued to be on high-end ventilatory support. The course was further complicated by the presence of septic shock. The 1st patient was taken up for a challenging procedure after spending 23 days on the mechanical ventilator. Diagnostic pleuroscopy revealed left-sided bullae and a surgical staple bullectomy was done. The right side showed a large bronchopleural fistula (BPF) on pleuroscopy, which was occluded using a customized endobronchial silicone blocker (CESB, described in 2018). This led to the reduction and finally, resolution of the bilateral PAL with subsequent removal of chest drains and weaning off the ventilator and oxygen. The second patient was managed with 2 CESB devices for occlusion of RUL anterior and posterior segment fistulae, followed by chest drain removal. These cases highlight effective out-of-the-box multimodality treatment using a combination of interventional pulmonary techniques and surgical stapling for a life-threatening bilateral PAL secondary to CARDS.

The Efficacy and Safety of Autologous Blood Patch for Persistent Air Leaks: A Systematic Review and Meta-Analysis.

Persistent air leaks (PALs) are associated with prolonged hospital stays, contamination and sustained infection of the pleural space, and significant morbidity. A fistulous tract between the alveoli and the pleural space is referred to as an alveolar-pleural fistula (APF), whereas a fistulous tract between the bronchiole and the pleural space is referred to as a bronchopleural fistula (BPF). There is no consensus on the treatment, and multiple modalities exist for the management of persistent air leak (PAL). Autologous blood patch (ABP) is a relatively safe and inexpensive method that has been used for many years for the treatment of PALs. We conducted an electronic database search between 08/24/2022 and 08/27/2022 in PubMed, Embase, and Cochrane using keywords. The following keywords were used: "Blood patch" OR "Autologous blood patch" AND "pleurodesis." Our study included all original studies with the prime focus on the etiology of PALs, clinical characteristics, procedural details of ABP, and outcomes of the proposed treatment. The primary outcomes that were the focus of our study were the time to seal the air leak, the time to remove the chest tube after air leak cessation, and the time to discharge from the hospital. To determine the safety of ABP, we also evaluated the procedural outcomes. Our findings suggest a statistically significant decrease in the time to air leak cessation when compared to the control group (mean difference of -3.75 {95% CI: -5.65 to -1.85; P=0.001}) with considerable heterogeneity of I2=85% and P=0.001. However, the difference was not statistically significant when a lower dose of ABP (50 mL) was compared to a higher dose (100 mL) (mean difference of 1.48 {95% CI: -0.07 to 3.02; P=0.06}) and considerable heterogeneity of I2=80% and P=0.03. There was no statistically significant difference in the time to discharge when compared to the control group (mean difference of -2.12 {95% CI: -4.83 to 0.59; P=0.13}) and considerable heterogeneity (I2=95% and P<0.001). When compared to the control group, ABP did not provide any statistically significant difference in the risk ratio for infection (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I2=33% and P=0.20}), pain (1.18 {95% CI: 0.52 to 2.65; P=0.70} and moderate heterogeneity {I2=33% and P=0.20}), and fever (0.54 {95% CI: 0.27 to 1.10; P=0.09} and no heterogeneity {I2=0% and P=0.50}). Our study concludes that using ABP caused a statistically significant decrease in the time to air leak cessation when compared to the control group. However, the procedure does not provide a statistically significant difference in the time to discharge from the hospital when compared to conservative treatment. Similarly, there was no statistically significant difference in the risk ratio for complications such as infection, pain, and fever when compared to conservative management. More studies need to be conducted to fully understand the efficacy and safety of ABP in the management of PALs.

The benefit of indwelling pleural catheter with ambulatory pneumothorax device and autologous blood patch pleurodesis in lymphangioleiomyomatosis with persistent air leak.

We report a 35-year-old woman who presented with dyspnoea and chest pain for 1 week. High-resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video-assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter (Rocket® IPC™; Rocket Medical plc; WASHINGTON) was inserted and the patient was discharged after 1 day with an atrium pneumostat (Pneumostat™; Atrium Medical Corporation, Hudson, NH, USA) chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL.

Autologous blood-patch pleurodesis for persistent air leak in an AIDS patient with pneumothorax.

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.

Intraoperative prevention and conservative management of postoperative prolonged air leak after lung resection: a systematic review.

Background: Prolonged air leak (PAL) due to an alveolar-pleural fistula (APF) is the most common complication after lung surgery. PAL is associated with an increased risk of morbidity and mortality, a longer chest tube duration, hence a prolonged hospitalization. Management of PAL may be challenging, and the thoracic surgeon should be aware of the possible therapeutic strategies. Methods: A systematic literature review was performed in PubMed, Cochrane Library, EMBASE, Ovid and Google Scholar. Title, abstract and full-text screening was performed, followed by structured data extraction, methodological quality assessment and Cochrane risk of bias assessment. Inclusion criteria were: case-control studies/randomized controlled trials (RCTs) comparing the new tested method with the standard of care to manage PAL after lung surgery; PAL due to APF; at least 10 patients; English-written papers. Results: A total of 942 initial papers from literature search, resulted in 43 papers after the selection. This systematic review found that the use of intraoperative measures as surgical sealants or pleural tenting, as well as a proper management of the chest drain and the use of blood patch or sclerosant agents seem to reduce postoperative air leaks incidence and/or duration and length of chest drain stay and hospitalization. Conclusions: Different measures have been described in literature to manage or prevent postoperative PAL. Most of them seem to be safe and efficient if compared to the "wait and see" strategy, even if large comparative studies that standardize the intra- and post-operative management of APF after lung resection are lacking and, actually, hard to conceptualize. However, there is a large consensus on the value of a preoperative PAL-risk stratification and on the necessity of tailoring PAL management or prevention's strategy and its timing on each patient's features.

Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation.

COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU/hospital discharge.

Prevalence, risk factors, and recurrence risk of persistent air leak in patients with secondary spontaneous pneumothorax.

Background: Persistent air leak (PAL) is common in secondary spontaneous pneumothorax (SSP), with risk factors only been determined for post-pulmonary resection PAL. Information about its risk factors and long-term outcome is, however, necessary to enable selection of treatment modalities for elderly SSP patients with comorbid conditions. Methods: A retrospective observational study was performed on chest drain-treated SSP patients from 2009 to 2018. The risk factors, long-term recurrent pneumothorax, and mortality rates of those with and without PAL were evaluated. Results: Of 180 non-surgical SSP patients, PAL prevalence for >2 days and >7 days were 81.1% and 43.3%, respectively. Bulla was associated with PAL >7 days (OR: 2.32; P: 0.027) and serum albumin negatively associated (OR: 0.94; P: 0.028). PAL resulted in longer hospitalization in the index episode (P: <0.01). PAL >7 days was associated with a higher pneumothorax recurrence rate in three months (HR: 2.65; P: 0.041), one year (HR: 2.50; P: 0.040) and two-year post-discharge (HR: 2.40; P: 0.029). Patients treated with medical pleurodesis were significantly older (P: <0.01), had higher Charlson Co-morbidity index scores (P: <0.01), and 77.8% of those who had PAL >7 days were considered unfit for surgery. Of these, pneumothorax had not recurred in 69.4% after two years (HR: 0.47; P: 0.044). Conclusion: Bulla was positively associated with PAL over seven days in SSP patients while albumin was negatively associated. PAL over seven days increased future recurrent pneumothorax risks, while elderly SSP patients unfit for surgery had acceptable recurrence rates after medical pleurodesis.

Pressure-dependent persistent air leak in a patient with secondary spontaneous pneumothorax.

An air leak lasting more than 5-7 days (persistent air leak, PAL) can complicate up to 40% of patients with secondary spontaneous pneumothorax. Chronic obstructive pulmonary disease is the most common cause of secondary spontaneous pneumothorax, and early surgical intervention has been recommended for patients with PAL. Bullectomy or blebectomy with concomitant mechanical pleurodesis by medical thoracoscopy or video assisted thoracoscopic surgery is considered definitive therapy. Unfortunately, the perioperative course following lung resection can also be complicated by air leaks leading to worse clinical outcomes. Post lung resection air leak can be pressure independent or pressure dependent (also known as drainage-related air leak). The distinction between these two entities is crucial as the management varies drastically. Pleural manometry may play an important role in the early diagnosis of pressure-dependent PAL preventing further unnecessary surgical procedures from being performed.

Endobronchial blood-patch: A novel technique for a persistent pleural air leak.

Introduction: 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. Clinical case: 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. Conclusion: 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.

"All things must pass" - Cutaneous migration of an endobronchial valve.

The Zephyr (PulmonX Inc., Redwood, CA) endobronchial valve (EBV), predominantly designed for lung volume reduction in emphysema, can also be used to close a spontaneous or post-operative prolonged air leak (PAL). We describe a previously unreported complication of cutaneous migration of an EBV, inserted for management of a PAL from a postoperative bronchopleural fistula (BPF), in a 62-year-old male following a right upper lobe posterior-apical (S1,2) segmentectomy. His PAL resulted in a chronic empyema which failed to respond to surgical debridement, anterior cavernostomy and pectoral myoplasty. Bronchoscopic closure of the air leak by EBV insertion resulted in clinical improvement but there was a residual chronic wound sinus through which the patient reported protrusion of a foreign body that was causing irritation. It was the EBV. We hypothesise that the BPF healed beneath the EBV causing it to dislodge but its route to the skin remains a mystery.