Prolonged air leak (PAL) is one of the most common complications after pulmonary resection. PAL is
associated with longer hospital stay, increased morbidity, and increased cost. PAL can be defined in various ways, but the
most commonly accepted definition is an air leak which prolongs the hospital stay. Patients with decreased lung function
and emphysema are at the highest risk for PAL, as are patients with intrapleural adhesions. PAL is also associated with
various risk factors for poor wound healing (e.g. steroids and malnutrition). PAL is more common after lobectomy,
especially upper lobectomy. Fissureless techniques and VATS surgery have been associated with a decreased risk of PAL,
as have buttressed staple lines, chemical sealants, and various measures to reduce the volume of the pleural cavity (such as
creation of an apical tent or iatrogenic pneumoperitoneum). These techniques may be used routinely, but are usually
employed only in high-risk patients or patients with an intraoperative air leak. Early use of water seal has been
consistently demonstrated to reduce the incidence of PAL, except when a patient develops an expanding pneumothorax or
worsening symptoms on water seal. Patients with PAL who tolerate water seal drainage can be discharged with a chest
tube still in place attached to a one-way valve or portable drainage system. For recalcitrant PAL, sclerosants and
endobronchial valves have both shown some success. Reoperation is required for <2% of patients with PAL.
Keywords: Chest tube management, complications, lung resection, morbidity, prolonged air leak, persistent air leak, thoracic
surgery, emphysema, intrapleural adhesions, lobectomy.
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