A prospective algorithm for the management of air leaks after pulmonary resection

Background. Air leaks (ALs) are a common complication after pulmonary resec tion, yet there is no consensus on their management. Methods. An algorithm for the management of chest tubes (CT) and ALs was ap plied prospectively to 101 consecutive patients who underwent elective pulm onary resection. Air leaks were graded daily as forced expiratory only, exp iratory only, inspiratory only, or continuous. All CTs were kept on 20 cm o f suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H2O of suction. If a pneumothorax was present without a n AL, the CT was returned to 20 cm H2O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry. Results. There were 101 patients (67 men); on postoperative day 1, 26 had A Ls and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) ( p = 0.005), increased age (p = 0.007), increased ratio of residual volume t o total lung capacity (RV/TLC) (p = 0.04), increased RV (p = 0.02), and an increased functional residual capacity (FRC) (p = 0.02) to predict the pres ence of an AL on postoperative day I. By postoperative day 2, 22 patients h ad expiratory ALs. After 12 hours of water seal, 13 of the 22 patients' ALs had stopped, and 3 more sealed by the morning of postoperative day 3. Howe ver, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Fi ve of the 6 patients with ALs on postoperative day 4 still had ALs on posto perative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry. Conclusions. Most ALs after pulmonary resection ale expiratory only. A low FEV1/FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Con version from suction to water seal is an effective way of sealing expirator y AL, and pneumothorax is rare. If an expiratory AL does not stop by postop erative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment. (C) 1998 by The Society of Thoracic S urgeons.