Good morning. It's the last day and I appreciate everybody coming out this morning. It's more than I expected. But we are here today, this morning, to talk about a situation that is extremely challenging and also extremely frustrating. We're going to present a few things that are new and some that are basics and I think we should have enough things to talk about. We'll be presenting all the talks in succession and leave the question and answer portion at the end of the talks. So I'm Phil Ong. I'm from San Antonio. These are my disclosures at the end of the slide but nothing relevant to this talk. So these are the objectives. This is the QR code but as you know from the rest of the conference, you'll have the QR code for the question and answer, for the ARS, when the questions come up. I'll give you time to scan that if you want. So let's start with a case. I'm an interventionist so most of my persistent air leaks are valve patients. So this is a typical valve patient. This is an 82-year-old male with severe emphysema with severe hyperinflation as you can see there. TLC 108% predicted, RV 194% predicted. After workup, it looked like the right upper lobe and right middle lobe were good targets and so we placed in the bronchial valves, I think three in the right upper lobe and two in the right middle lobe. And in the PACU, the patient developed chest tightness. I don't know if it projects well but you can see a small pneumothorax. You know, I was there sitting in the PACU looking at the portable x-ray, people taking the x-ray and I looked on the machine. I said, oh, it's a tiny pneumothorax. I'll leave this alone, right? And then I walked away and then it turns out after I walked away, the radiology tech decided to shoot another one because he didn't completely take the left sulcus. And so he had the patient lift himself up from the bed using the railing of the bed and this is what happened. This is three minutes later after I walked away. And so I took the sandwich out of my mouth, which I was doing, and you can see the lungs are folded over. The patient's saturation was 90% and oxymath, his baseline was three liters. And what would you do next? Okay, which is what we did because we don't want to deal with that. And so after we inserted a small pigtail, actually a French pigtail, we saw that, I'm sorry, we saw that this one was basically gushing air like a balloon. And so when this happens to us, no matter what we do in pulmonology, and especially since you were responsible for the procedure, what happens in your mind is like, oh no, what have I done? Should I have done something differently? This seems like a large air leak. Is this patient going to get stuck in the hospital for one month or two months with a chest tube? How about suction? Will the patient need more chest tubes, two, three, four, you know, large bore, small bore? How do I know when to take the chest tube out? Is this going to recur? And then you're going to have a noon conference and people are going to have all these suggestions to take care of the air leak. When do I call another service for help? Should I call surgery now? And what's surgery going to do? This patient has severe emphysema. Do I need additional procedures? When we talk about air leak, it's usually either an alveolar pleural fistula or a bronchopleural fistula. But we always call it bronchopleural fistula, but it's not necessarily true. In this case, in valve patient, I don't know if everybody's familiar, we cause atelectasis for lung volume reduction. In this case, it was the right upper and middle lobe. What happens is that the remaining untreated lobe, which is the right lower lobe, hyperinflates. And that causes volume trauma and causes a leak in the pleura. So the air leak happens in that manner. So when you get an air leak, usually, in normal cases, the pressure in the lungs is positive and the pressure in the pleura is negative. And the airflow goes from a positive to negative pressure as a pressure gradient. And this airflow continues until the pressure equalizes or the communication or the fistula closes. And this gradient is affected by the defect of your diameter. And the pressure gradient between the lung and the pleural space is also influenced by your external gradient. So you can have additional gradients in the airway. So if you're adding positive pressure, that increases the gradient. If you have a chest tube, that increases the gradient as well, because you're applying negative pressure. And the gradient is also influenced by elastic recoil forces. If your lungs are stiff, if your chest wall is stiff, if you're an obese patient, that changes the dynamics of the gradient as well. The lung will recoil to a new position of equilibrium established by the chest wall and the lung recoil force, depending on how stiff your lungs are and what other forces there are you've introduced to the system. When you put a chest tube, right, in a patient with pneumothorax, the chest tube placement provides another pressure gradient from the pleura to the chest tube drainage system. And the underwater seal that we put in provides a method for monitoring the air leak, whether it's still there or not. And that's when we round on the patient and not really look at the face of the patient, but look at the chest tube. And the whole team is looking at the chest tube and not at the patient. So typically, we can grade the severity of the air leak several ways. One is with the air leak meter. With the air leak meter at the bottom, it's usually from one to seven, five or seven, depending on the brand you're using. And the larger the number is, the bigger the air leak. But Dr. Serfolio in surgical patients has described, and this is what most interventional pulmonologists use to grade air leaks, is that has divided four categories of air leak. With C, meaning continuous air leak, both in tidal respiration in the air leak chamber. Fe means forced expiration. It only occurs when you cough. And E and I are expiratory and inspiratory only in tidal breathing. 98% after surgery, pulmonary surgery, 98% of spontaneously breathing patients are either E or forced expiration air leaks. So when do we say that an air leak is persistent, right? Usually, it's just defined arbitrarily. And traditionally, it's been defined as five to seven days. The old BTS criteria actually considered persistent air leak as persistent after 48 hours if the patient has underlying pulmonary problems in secondary spontaneous pneumothorax. The Society of Thoracic Surgeons defines air leaks as air leaks lasting more than five days. But is time really the only way? If you have an air leak, are you sort of committed to wait five days or seven days before you call it persistent? Is this fair to the patient? Is there a way to predict whether you'll have a persistent air leak? Now in surgical patients, Dr. Serfolio noticed that actually, in his paper, defined air leak as an air leak that prolongs the hospitalization. He noticed that on post-operative day three, if the air leak is still moderate, it will likely not seal the next day. And he also noted that in patients with large level six or seven air leaks on the first post-operative day, they continue to have an air leak on day four, irrespective of chest tube management. And risk factors for air leak include low FEV1, pleural adhesions, upper resections, steroid use, male gender, lobectomy, and large air leak. In pneumothorax, it's been shown that for primary spontaneous pneumothorax, the mean duration is about five days. And the length of that is about twice as long for people with underlying pulmonary problems, secondary spontaneous pneumothorax. And a substantial proportion of patients persists beyond seven days. In primary, it's 26%, and secondary is 39%. In surgery, this results in significant healthcare costs. Patients stay in the hospital for longer. The incidence could be as high as 46% in the net trial, although that's a bit of an older trial in the early 2000s. Post-lobectomy, it can be as high as 26%. And because of the prolonged hospitalization, it can result in significant morbidity from complications, including infections, such as post-op pneumonia. But it hasn't been shown to have an increased risk of mortality. So the length of stay after lobectomy in people with persistent air leak is twice as long, seven versus 14 days in these patients. Now, the more we do minimally invasive procedures in the ICU, lines, ECMOs, robotic bronchoscopy, you know, all specialties have been introducing needles in the body. So patients, this will probably just increase in incidence. Our patients are also increasingly sicker and have more underlying comorbidities, including emphysema and pulmonary fibrosis. Now, in 2017, the folks in Albany, Dr. Chopra, had a patient post-right middle lobectomy with a persistent air leak for two weeks. And they basically attached a pleural manometry to these patients because they were wondering what was the pressure looking inside this patient. And he noticed that these are the manometry tracings. This is the baseline side. So these spikes that are patients when the patient is coughing. So on water seal after the cough, the pleural pressure immediately afterwards is lower than baseline, as you can see, due to discharge of air from the chest tube. And after that, the pleural pressure rises to baseline until the pressure gradient is equalized. On water seal, you can see that it rises. But when the chest tube is clamped, on this patient, he noticed that even if there was an air leak, when the chest tube is clamped, the pressure remains stable. And he was able to remove the chest tube. And so he called this, he postulated that the chest tube itself created the pressure gradient for the air leak to occur, right? The mere presence of the chest tube created the gradient for the air leak to be there. If the chest tube wasn't there, the pressure would be equalized and the air leak would not be occurring. And so this provided the impetus for a prospective study where he reviewed 225 post-surgical patients with persistent air leak for more than five days. And he found 22 patients that had persistent air leak in this series. And he clamped the chest tube for 20 minutes and attached the pleural manometer. And to see whether this phenomenon is occurring and what kinds of things are happening to these patients. And so this is, he noticed this one where the air leak persists. This is our classical notion of a persistent air leak where the leak continues. You know, when you clamp the chest tube, the pneumothorax gets worse. So for this patient, after clamping, you can see that the pressure tracings increase. And this is what he called pressure independent or drainage independent persistent air leak. So whether the chest tube is there or not, the air leak continues. So that is drainage independent persistent air leak. And this, he postulated this to be resulting from trauma to the visceral pleura. In this case, lung resection. And then this is the one that he described wherein even if the chest tube was clamped, the manometry remains stable. So this is what he called drainage dependent. So the air leak was dependent on the drainage. So this is theorized to be the gradient created by the chest tube perpetuating the air leak to be present. So that's drainage dependent or pressure dependent air leak. So what he noticed that majority of the patients in his series, he only had 20 patients with pleuromanometry and out of the 220 patients, is that patients with drainage dependent persistent air leak and patients with drainage independent persistent air leak had a longer hospital stay and longer chest tube indwelling time than those patients with drainage dependent persistent air leak. And most of the patients with drainage dependent air leak had grade one or two air leaks compared to those with drainage independent air leak, showing that you can possibly differentiate patients that you can clamp the chest tube using pleuromanometry. So you don't have to wait the five to seven days. If you clamp the chest tube, you put the pleuromanometer and if the pleuromanometer is stable, maybe you can remove the chest tube. Maybe the air leak is perpetuated by the gradient, even if the patient was just in water seal. So moving on, there's a new, this product is not new. Some of us have had this in our centers. This is a digital drainage system. Personally, we have one in our hospital, but it's lost. But it is something that's available in some centers. So this system basically is a digital system that allows measurement of the air leak. Okay. And it measures the drainage and four patterns have been described where, you know, there's no air leak, air leak that is intermittent, an air leak that is decreasing, and an air leak that is variable. And what this shows basically is that the incidence was highest in the patients with the variable group. And only half of the patients, 0.5 of the patients of the none had air leak more than five days. So basically what this shows is that they're able to categorize the air leaks and able to plan the air leaks based on the amount of air leak that is being shown by that digital drainage device. And the similar study was also been shown. This was in the surgical population. So they also did this in a pilot study of 13 patients with spontaneous pneumothorax. And they were also able to look at and predict which patients are able to be removed. Like this patient, for example, had an air leak, which is about 10, less than 100 ml per minute. But in the, you know, a small, a small spikes occur while the chest tube is occurring, which is a, this patient required surgery. So in our patient, we scheduled this patient for valve removal. We typically remove one valve to allow for partial lung expansion after valve treatment after five days. But the air leak was small. And after post-operative data, we decided to hold off on removal of the valve. After day 10, we were able to remove the chest tube without doing additional procedures and the patient was discharged. And so in summary, these are just the things that are sort of available for us for monitoring. None of these are expensive, actually, the manometer and the digital drainage device, but something to consider for us to be able to categorize our patients. Thank you. And now we have Dr. Lakshmi Modambi from Oregon. All right. So I'm going to be focusing on floral strategies and persistent air leaks. My name is Lakshmi Modambi. I'm an associate professor at Oregon Health and Science University. I primarily work at the VA. I'm at the Portland VA. This is a picture of the aerial tram. This connects our main university to the waterfront property. If you come to Portland, please come and visit us in the summer. We have a beautiful view of the Willamette River and then we can see Mount Hood from here. So if you visit, this is one little thing that you should, you should just get on the tram. I'm going to be very brief reviewing the plural strategies and persistent air leaks and the data supporting it. All right. So before I jump to the strategies, I want to talk first about how to approach these patients, right? Dr. Ong nicely described the physiology and the variable different causes and so on. But when we see a patient, probably in any disease state, the best treatment option is the one that the patient can tolerate and the one that's going to provide the highest likelihood of cure. So although, you know, we are very excited about minimally invasive procedures and techniques, we are, I'm an interventional pulmonologist myself. We're all pulmonologists here probably, you know, hate to say it, but the surgeon is the first person you should think of. As soon as I put the chest tube in, that's the first thought I have. If this pneumothorax doesn't resolve, can this patient tolerate surgery? And over time, I have realized just working in this field that the patient may not be surgical on day one, a surgical or operative candidate on day one, but a good surgeon is able to sometimes rehabilitate or prehabilitate a person, provide nutritional support and make them a surgical candidate. So of course, I work in a VA. All of my patients have terrible lung disease. And there are situations where when none of the conservative methods have worked, our surgeon, you know, rehabs the patient to surgically operate. So don't rule it out as an option. And that's what I want to start with. It is something that's easy to forget, especially since pulmonary is usually a first person who's called when this problem occurs. The second thing I look at is the lung expanded or not. And this has treatment implications. It is also important to understand the impact of suction. There are situations where suction is necessary to keep the lung open. And there are situations that it's not. And again, there are treatment implications based on these two. And the third, of course, is a patient symptomatic or not. We have all seen patients that have a tiny pneumo and cannot tolerate it at all. And we have patients who have complete lungs down with terrible emphysema but are very good functionally and are able to tolerate it. And it helps you sort of triage what the next step is, gives you time if the patient's stable. If not, you might need to intervene faster. All right. So just getting to the treatment options, the plural strategies, there's chest tube and observation, autologous blood patch and chemical pleurodesis. And we'll start with chest tube drainage and observation. So as Dr. Ong said, most persistent air leaks will resolve on their own, right? But the trade-off is the morbidity associated with a prolonged chest tube placement. So the longer the chest tube is in place, they're at increased risk for developing pleural space infections, about 10% to 15% in the literature. Tubes get dislodged, reported up to 13% of cases. And then don't forget the social support system necessary for a patient to go home and take care of the chest tube. So barring that, the situations that it may be appropriate to discharge a patient with a chest tube is one where you are able to observe a nice decline or trend in reduction in the air leak. So you know this tube will probably come out in a day or two. The patient's really doing well. They don't need suction. They can manage this at home. It will be okay for them to go home with a chest tube. The other situation is when all of the methods I've described have not worked. Sometimes there's no other option, right? And you just have to give it time. There is a debate. There are two different schools of thought on the impact of suction, right? There's a group of people who think suction is a good thing and that it helps evacuate air from the pleural space at a rate faster than it's being released through the visceral pleura defect. And in those situations, that helps lung expansion. And there's exactly the opposite school of thought that suction increases the pull through the visceral pleural defect, preventing the healing of the defect. I think that that paper, the physiology paper from Dr. Chopra, which was in the post-operative setting, is a real key idea. If we are able to identify which leaks in this setting, the secondary spontaneous pneumothorax, not in the operative setting, that might be a way to help us decide, is suction helping in this case or not? And it's probably a more objective marker than what we use right now. Okay, let me move on then. So autologous blood patch, what is it? It's simply the installation of the patient's own venous blood through a chest tube. How does it work? Well, it forms a clot on the visceral pleura and blocks the leak. Other thoughts are that it causes inflammatory changes in the pleura and allows for pleurodesis. So overall, there are very few direct comparisons between any of these strategies that I and Dr. Tachutara are going to be speaking about. But I thought I'd highlight the studies that do actually compare. And there is a meta-analysis that was recently performed about a year ago. So let's start with the RCTs first. So early autologous blood patch has been directly compared with conservative management with chest tube alone. This was a study that randomized about 23, 24 patients into two groups. If they had a persistent air leak on day three, 50 ml of blood was instilled into group A. And the other group was just monitored. They defined success as cessation of air leak at day seven, along with absence of recurrence of a pneumothorax once the chest tube was pulled out after seven days. So very conservative definition of success. And you can see that those patients that received an autologous blood patch had a greater degree of success, 78% versus 8%. They also had a reduced duration of leak, reduced duration of drain placement, and length of stay. And interestingly enough, in this paper, only 30% of patients in both groups had a fully expanded lung. So right now, if your lung's not fully expanded, and if you're not a surgical candidate, the options are autologous blood patch or endobronchial therapy. So this is an interesting paper that shows us that earlier, using ABP earlier is probably better. And I'll get to the meta-analysis to tell you what it actually shows from all the studies. The second paper is another interesting paper, which is a randomized trial. It was done in India, published a year ago. Randomized 19 patients into two groups. One receiving autologous blood patch, again, 50 ml on day three, and the other group receiving 500 milligrams of doxycycline on day three. They defined success as cessation of air leak on day seven, and they did not find a difference in success rates. They also did not find a difference in median time to closure, and where the difference was, was in the side effects. The patients who had doxycycline had a higher incidence of pain, higher severity of pain, and more fever. So they postulated that, well, they summarized that autologous blood patch is as effective as chemical doxycycline pleurodesis, but it's better tolerated. The third, you've heard me mention 50 ml twice, but in the literature, the ranges of the dose range from 50 to 200 ml. Is there a dose response? And it looks like there is. This was a randomized trial that was published, that was done in Egypt, randomizing 11 patients into four groups. They received either 0.5 ml, 1 ml per kilo, 2 ml per kilo or normal saline, and here they instilled the autologous blood patch on day seven, so longer than what I've described so far. And in this study, the group that received 1 and 2 ml had a greater degree of cessation of air leak on day 13 compared to the other two groups. So there does seem to be a dose response, and this was also another study. This looks like a retrospective study, but there was some question on the methodology, but basically they compared 60 ml to 120 ml. And again, 120 ml, you see the much lower length of stay, duration of chest tube, number of pleurodesis needed, and so on. All right, so let's come to what we know from the meta-analysis. And there are about seven studies observationally that met the methodology in the meta-analysis. But what we know, there's a ton of heterogeneity in the studies, right? The definition of persistent air leak ranging from two to seven days, lung expansion ranging from 30% to 100%. The dose of ABP is different. The way you do the procedure is different. So it's really hard to come to any definite conclusion. But we were able to say, they were able to say that if you instill an ABP earlier, less than five days, there is a higher likelihood of cessation of air leak by day seven. So about 70% in the studies. They all require, most of them required repeat installation, so it's okay to repeat an ABP. And it is more effective when the lung is fully expanded. They also saw that overall the length of stay is shorter. And those that received ABP in comparison to conservative therapy alone had a reduced recurrence rate. Okay, so now let's come to chemical pleuridesis. And so if you thought that the data I presented was sparse for ABP, it's far worse for chemical pleuridesis. Now let me just say that the data for autologous blood patch and chemical pleuridesis in the post-op setting is actually much more robust. And I'm assuming our surgeon is going to be speaking about that. So I'm not going to mention that. But in the secondary spontaneous pneumothoraces not related to surgery, chemical pleuridesis has not been actually studied robustly as a primary treatment option. So we have one subgroup analysis in a large study that compared tetracycline to conservative therapy alone in secondary spontaneous pneumothoraces to prevent recurrence. So they did a subgroup analysis of patients who had a persistent air leak in that. There were about 40 patients, if I remember. And chemical pleuridesis with tetracycline did not cure any of these. They continued to have a persistent air leak. There are other studies that have intermittently included patients with persistent air leaks. So it's not been primarily studied. And I think that is reflected actually in the BTS guidelines as well. They updated it this year where they actually make no mention of chemical pleuridesis as an option to treat persistent air leaks in spontaneous pneumothoraces. And so I don't know if any of you have seen this movie. It's basically about different parallel universes. So all of us, you know, I don't know if all of us, but I know for sure anecdotally myself, I have seen chemical pleuridesis be used in persistent air leaks, and it sometimes works, right? And although there isn't data to support it, I think the conclusion I can make is it is on my algorithm, but it's low on my algorithm. It's not the first thing I think of starting. I would start with autologous blood patch. I would consider endobronchial therapies. And then if all else fails and if the patient is the perfect protoplasm, right, lungs expanded, not too old, no risks for complications with chemical pleuridesis, I would consider it. But there's no real data to guide us here. All right, so now we can jump to endobronchial therapies. Thank you. Good morning, everyone. So today I'll be talking about the bronchoscopy strategies in managing persistent air leak, mostly in plants and adhesives. My name is Joseph Tachitara-George. I'm an associate professor of medicine at the University of Birmingham, University of Alabama at Birmingham. I don't have any relevant disclosures associated with this talk. These are my objectives. I'll be discussing various options, bronchoscopic options available in treating persistent air leak as well as review one-way bronchial valves in detail. We'll start with the case that we had. It's a 33-year-old man admitted with gunshot wound to the right chest causing hemopneumothorax, lung contusion, and pulmonary lacerations. He underwent right vats and decortication, wedge resection of the upper lobe, and mechanical pleuridesis. He continued to have persistent air leak post-op and we did clamping trials. It did not tolerate that. So we were consulted for a possible bronchoscopic intervention in this patient. So when it comes to bronchoscopic intervention when we got consulted, what options do we have? We have a lot of options that are reported, no robust data available. Of the multiple options, one-way bronchial valves are the most commonly used and we have the most data available on. So the concept of endobronchial control of bronchopolar fistula was first reported in 1977 when fishing weights were used to block the culprit airway in a patient with ARDS and persistent air leak. Then in 2005, the first report of one-way endobronchial valve was reported from Australia in a patient with bronchocutaneous fistula and this was an emphasis valve on the right lower corner. That is the predecessor of sephir valve. Now we have two different types of one-way valves available. One is a spiration valve from Olympus and a sephir valve from Pulmonics. Both these valves serve the same purpose but they are different. Spiration valve is an umbrella-shaped valve which comes in three different sizes, 5, 6, and 7 millimeters, whereas sephir valve is a duckbill-shaped valve which comes in two sizes. Both are made of a nitinol framework. However, the spiration valve has a polyurethane covering and sephir valve has a silicon covering. Spiration valve is held in place with anchors, about five of them, whereas the sephir valve is similar to our stents that are held in place with the radial expansive force. And both the valves are FDA-approved for bronchoscopic lung volume reduction. However, spiration valve is approved also for postoperative persistent air leak. This is a summary of data that we have available on bronchial valves. Most of them, except almost all of them except one are retrospective studies with relatively small sample size. Two of the studies were strictly looking at postoperative persistent air leak, whereas the others had a heterogeneous population when it comes to etiology. And you can have anywhere from one to four valves in a patient with persistent air leak. Patients who are postoperative and having persistent air leak require lesser valves compared to patients with secondary spontaneous pneumothorax. Coming to success rate, it depends on how you define success rate. All the studies define their success rate differently. Some authors called complete cessation of air leak as a success rate, whereas the others called a combination of cessation of air leak or reduction in air leak. So that's where there's a wide difference in the success rate that you see among studies. The success rate was better in postoperative air leak patients when compared to the secondary spontaneous pneumothorax patients. And when it comes to complications, there were no major complications. Most of the studies did not have any complications at all. The others had mostly valve migration or valve expectoration and some infections or mild increase in oxygen requirement. So what we can take away from the data we have on valves is that one, it's a relatively low-risk procedure. Two, it works better in patients with postoperative air leak than secondary spontaneous pneumothorax. You have a better luck in controlling postoperative air leak, probably because of relatively healthy parenteral in patients who undergo surgery than patients with secondary spontaneous pneumothorax. So our patient, we took him to the OR, did balloon occlusion, isolated the airway. He did not have an apical segment, so we had to block the entire upper lobe. His air leak stopped, and his chest x-ray improved. He continued to have a small, localated, unexpandable lung, but the rest of the lung stayed up. And we took the valve out in eight weeks. Another option that we have when it comes to endobrongial intervention is endobrongial von Geneve spigots. These are silicon bronchial blockers. These are not one-way valves. This blocks the entire airway. We don't have a lot of data on this, but the limited data shows that it's technically successful in about 96% of the patients. And these are placed bronchoscopically using flexible forceps introduced into the isolated airway that is leading to air leak. Complete resolution of air leak was seen close to 40% of the patients, and reduction in air leak about 38%. If you combine both, that goes along with the data on bronchial valves as well. Coming from, going from occlusive devices, we are going to chemical occlusion. There are reports, I've not personally used this, but there are reports of tissue adhesives that are used. These are mostly used in surgery or for skin laceration, skin incision, and dressing. These are, these can be introduced into the airway using a larger catheter. And these work better if the bronchial fistulae is smaller. However, we have to be mindful about, you know, touching the tissue or bronchial wall because that can get stuck to the tissue. And while we take it out, we can cause injury. It can also potentially occlude the bronchial scope working channel where we like to wash it with acetone to reopen it. So those are some of the important things to keep in mind. Other agents that you can use are hemostatic agents. One is fibrin glue or polyethylene glycol. I've used fibrin glue on various occasions. This is a mixture of fibrinogen and thrombin. One problem that is reported in case reports as well as I've personally had was if you put excess of this glue, it can form a clump and then a patient can cough it out or occlude the airway. So we have to be careful how much you, you know, how much you instill at the site. We also have other options of absorbable sponges or regenerated cellulose like Surgicil or gel form that we are all familiar with. There are reports of this being used in some cases. There are submucosal injections or tissue expanders that can also be used or sclerosing agents that can be injected into the airway. Those were the chemical methods. There are thermal methods that are reported. The same methods that we use for treating endobrongial tumor like argon plasma coagulation or YAG laser. You cauterize the airway and form a scar and you can seal the fistula, relatively smaller fistula. However, the tissue has to be normal. If you have infection or a tumor in the tissue, then it won't work. The other method is we are all probably familiar with the coils that our interventional radiologists use. These are vascular occlusion coils that are used along with sealants where the coils function as a matrix to hold the sealant in place. This can also be used on a case by case basis. These are some of, you know, we don't have, most of these are case report based options, but we don't have any good studies on this. The other one, in patients with persistent air leak from a bronchopulvar fistula after surgery like a lobectomy and a mnemonectomy, septal defect closure device has been reported in treating these patients with about 82% success rate. The only drawback with this is once you place this in, you cannot take it out. The tissue will grow around it and that's a permanent implant unlike the stems that we place and we can take it out. So this is a case of 55-year-old man with post double lung transplant. He had a right anastomotic dehiscence and persistent large pneumothorax and continuous air leak and that white thing that you see there is the pulmonary artery. So he was treated with a Y-stent in the right main stem and his air leak stopped. He was successfully decanalated, extubated, left the stent in for about a year and then took it out and he is doing well and full-time working right now. And there are other reports of stents being used, metallic and silicon stents being used in the airway for persistent air leak. We talked about the, you know, autologous blood patch as a plural intervention. There are reports of this being used in the airway but along with other methods like go in and place surgical seal or absorbent hemostatic agent and place instant blood on it and that way you can seal the leak. But this often needs something else also along with that to achieve complete pleurodesis. So in summary, like Dr. Modambi was saying, you know, any of these patients with air leak or a pneumothorax, first thing is always consult with your surgeon. Bronchoscopy intervention can be considered if the patient is not a surgical candidate or if the surgical approach fails. And valves are more successful in managing postoperative persistent air leak and least successful in secondary spontaneous pneumothorax. That's likely because of the, you know, patients with secondary spontaneous pneumothorax as an unhealthy or destroyed parent tumor. Adhesives and sealants can be considered on a case to case, case by case basis. Septal defeclosure device and stents can be considered in fistulas arising from the central airways. And some patients, especially the ones with parenchymal lung disease, they may need a combination of both plural and bronchoscopic approach to manage their air leak. So that's it for now. Thank you. Hello, everyone. I'll be presenting on the indications and options of surgical management. Dr. Tsai, he's my mentor, who's here in the audience has, along with this team of faculty up here, have given me the opportunity to give this talk and this portion of the talk. But my name is Akin Erroll. I'm a general surgery chief resident here at the University of Hawaii. I have the fortunate opportunity to train in one of the best places in the world. And we have no disclosures. Our objectives today are going to be to review a brief summary of what we've already discussed earlier. We're going to understand the indications of surgical management and its nuances. And we will review some of the literature for surgical approaches, specifically for pleurodesis. So in brief, treatment option number one, conservative management. As mentioned before, this is often successful in a majority of cases. However, it comes at the cost of prolonged hospital length of stay, which increases the cost burden to our healthcare system. Option number two, chemical pleurodesis, has been studied. It's a fairly well tolerable procedure with some pain, if we can give some lidocaine as well as pain management to these patients. But again, the success of these are not as good in the spontaneous pneumothoraces, unlike autologous blood patches. These have shown very promising results in literature and are often an excellent alternative choice to chemical pleurodesis, especially in spontaneous pneumothoraces. And lastly, as just discussed, endobronchial treatments are getting more and more innovative and becoming more and more successful and definitely an option, especially in those cases postoperatively where other management options have failed. So what do we do when, despite all of this, the air leak continues to persist? First we have to discuss what is the cause of the air leak? Is this a postoperative air leak? Is this a technical issue? Is it quite a large air leak? Is it a large bronchopleural fistula? As these large air leaks, as discussed earlier, just don't resolve on their own. What's the duration of the persistent air leak? As we noted from earlier, the longer an air leak persists, the more difficult it is to seal on its own and conservative management is more likely to fail. Is the lung still collapsed? This essentially renders certain options not amenable to treat the pneumothorax or the persistent air leak. For instance, if the lung is collapsed, chemical pleurodesis is not a good option as apposition to the chest wall is integral for the success of the therapy. Is the patient symptomatic? Are they worsening in their symptoms? Are they having worsening dyspnea on exertion, worsening subcutaneous emphysema? That's important as well. And lastly, their functional status and surgical candidacy that goes without saying. And I think getting the surgeons involved early in these predicted persistent air leaks is good to be able to optimize them for surgery in the future if needed. So again, this is when all this fails. That's when surgical management comes into play. But to understand the persistent air leak managements, we first have to categorize these into two umbrella categories. Postoperative versus the non-postoperative leaks. So we'll talk about postoperative first. But before we delve too far into it, I want to talk about can it be prevented during the initial operation? So what can we do intraoperatively that reduces the incidence of persistent air leaks? Surgical approaches have been studied since the 90s. VATS versus open initially to show the effectiveness of VATS. And no significant difference has been shown for the incidence of persistent air leaks postoperatively dependent on the choice or modality of surgical approach used. The remaining approaches have also been studied. In a more recent 2023, just published this year by our Italian colleagues, a systematic review, buttressing was evaluated in the general literature. There was no significant difference in preventing a persistent air leak. Stapler type reinforced, pledged the brand as well as bovine pericardium was evaluated and showed no significant difference. Sealants, as the ones listed, have been studied predominantly in case series or small case control studies. And these have shown favor towards the use of these sealants intraoperatively to prevent persistent air leak and decrease the duration of the chest tube postoperatively. Autologous fat pads are more and more used, especially with fiber and glue agents. These also have, as shown in the picture here, have also shown decreased persistent air leaks postoperatively and are a good option, especially if we can isolate that air leak intraoperatively. Pleural tenting or an apex pexi or apexi, as some might say, is a new kind of more up-and-coming intraoperative modality that can be used, especially in upper lobectomies. As we noted before, upper lobectomies have a higher rate of persistent air leaks postoperatively. But this reduces that post-surgical residual air space, allowing apposition to the chest wall and then also improving postoperative air leaks. Now let's talk about the air leaks that are still leaking. So if the leak is pretty big, if it's large, if it's a technical issue, the answer is pretty quite simple. It's just like plexi tape. You find the hole and you seal it. So this often is through buttressing the staple line. Targeted sealant therapy has shown a lot of promise as well intraoperatively, but simply find the hole and seal it. So now let's talk about spontaneous or non-postoperative air leaks. These are the ones that usually persist when we get involved as surgeons. Predominantly they're treated with AVATs as a therapy of choice, but open surgery is not a crime. And it can still be done, especially in those patients that are unable to tolerate either single lung ventilation, intermittent apnea, or AVATs modality. Mechanical pleurodesis or chemical pleurodesis in this systematic review by Sim et al. in 2020 noted favoring chemical pleurodesis in the postoperative patients for recurrence rates of the incidence of a persistent air leak or repeat air leak. Unfortunately, or I guess I should go without saying that one out of the seven studies that was included was a randomized control trial, whereas the remaining studies were not. Similarly, pleurectomy has been evaluated compared to pleurodesis. Pleurectomy has shown no significant difference, at least in the systematic review, compared to pleurodesis in terms of reducing the incidence of postoperative air leaks. And then it has been evaluated for hospital length of stay as well as chest tube duration, showing a mild favor towards pleural abrasion or pleurodesis. Although if we look closely, it's 0.25 day mean difference and 0.3 day mean difference, which is very minuscule and likely does not make a clinical difference. In fact, when they adjusted for the weights of the studies that were included, there was both the hospital length of stay and chest tube duration fell out of significance. And lastly, the operative time mean difference was 13 for pleural abrasion. Pleurectomy often requires more time as we delicately remove the pleura or the majority of it to allow the scarring to happen. So even though it shows comparable results, it is a more lengthy procedure. So in summary, what did we discuss? We discussed indications for surgery. These rely on conservative management when these fail. A large persistent air leak. These often will not resolve on their own. When therapies are not amenable to conservative therapies, as we discussed, when the lung will not reinflate. Worsening symptoms and an appropriate surgical candidate that we can definitely work on optimizing their comorbidities. And then surgical options include vats or open. A blobectomy should be combined with a sort of pleurodesis or pleurectomy. Chemical is better, at least in studies, compared to mechanical pleurodesis. And then lastly, adjunct intraoperatively that can be used, although the data is still not very certain. So with that, thank you.

persistent air leaks

conservative management

autologous blood patch

endobronchial therapy

chemical pleurodesis

surgical management

bronchopleural fistula

reinforcing the staple line

patient's condition