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Pressure-dependent persistent air leak in a patient with secondary spontaneous pneumothorax. Am J Med Sci 2022; 364:782-788. [PMID: 35787363 DOI: 10.1016/j.amjms.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/03/2022] [Accepted: 06/27/2022] [Indexed: 01/25/2023]
Abstract
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.
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Saha BK, Bonnier A, Chong WH, Chenna P. Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema. BMJ Case Rep 2021; 14:14/11/e246671. [PMID: 34799393 PMCID: PMC8606771 DOI: 10.1136/bcr-2021-246671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Patients with SARS-CoV-2 pneumonia can suffer from pneumothorax and persistent air leak (PAL). The pneumothorax occurs with or without pre-existing lung disease. PAL refers to air leak lasting more than 5-7 days and arises due to bronchopleural or alveolopleural fistula. The management of PAL can be challenging as a standard management guideline is lacking. Here we present the case of a 42-year-old smoker with COVID-19 who presented to the hospital with fever, cough, acute left-sided chest pain and shortness of breath. He suffered from a large left-sided pneumothorax requiring immediate chest tube drainage. Unfortunately, the air leak persisted for 13 days before one-way endobronchial valve (EBV) was used with complete resolution of the air leak. We also review the literature regarding other cases of EBV utilisation for PAL in patients with COVID-19.
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Affiliation(s)
- Biplab K Saha
- Pulmonary and Critical Care Medicine, Ozarks Medical Center, West Plains, Missouri, USA
| | - Alyssa Bonnier
- Department of Nursing, Goldfarb School of Nursing at Barnes-Jewish College, St Louis, Missouri, USA
| | - Woon Hean Chong
- Pulmonary and Critical Care Medicine, Albany Medical Center, Albany, New York, USA
| | - Praveen Chenna
- Pulmonary and Critical Care Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
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3
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Jin R, Zheng Y, Gao T, Zhang Y, Wang B, Hang J, Li H. A nomogram for preoperative prediction of prolonged air leak after pulmonary malignancy resection. Transl Lung Cancer Res 2021; 10:3616-3626. [PMID: 34584861 PMCID: PMC8435390 DOI: 10.21037/tlcr-21-186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
Background Prolonged air leak (PAL) is one of the most common postoperative complications after lung surgery. This study aimed to identify risk factors of PAL after lung resection and develop a preoperative predictive model to estimate its risk for individual patients. Methods Patients with pulmonary malignancies or metastasis who underwent pulmonary resection between January 2014 and January 2018 were included. PAL was defined as an air leak more than 5 days after surgery, risk factors were analyzed. Forward stepwise multivariable logistic regression analysis was performed to identify independent risk factors, and a derived nomogram was built. Data from February 2018 to September 2018 were collected for internal validation. Results A total of 1,511 patients who met study criteria were enrolled in this study. The overall incidence of PAL was 9.07% (137/1,511). Age, percent forced expiratory volume in 1 second, surgical type, surgical approach and smoking history were included in the final model. A nomogram was developed according to the multivariable logistic regression results. The C-index of the predictive model was 0.70, and the internal validation value was 0.77. The goodness-of-fit test was non-significant for model development and internal validation. Conclusions The predictive model and derived nomogram achieved satisfied preoperative prediction of PAL. Using this nomogram, the risk for an individual patient can be estimated, and preventive measures can be applied to high-risk patients.
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Affiliation(s)
- Runsen Jin
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuyan Zheng
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Taotao Gao
- Department of Thoracic Surgery, Huainan Eastern Hospital Group, Huainan, China
| | - Yajie Zhang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bingshun Wang
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junbiao Hang
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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4
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Yanagihara T, Maki N, Wijesinghe AI, Sato S, Saeki Y, Kitazawa S, Yamaoka M, Kobayashi N, Kikuchi S, Goto Y, Ichimura H, Watnabe S, Taguchi T, Sato Y. Efficacy of Alaska pollock gelatin sealant for pulmonary air leakage in porcine models. Ann Thorac Surg 2021; 113:1641-1647. [PMID: 34102175 DOI: 10.1016/j.athoracsur.2021.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/22/2021] [Accepted: 05/06/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Postoperative prolonged air leakage is a frequent complication following lung resection. We have developed a new sealant based on a hydrophobically modified Alaska pollock-derived gelatin (ApGltn) sealant. The purpose of this study was to evaluate the adhesive strength of the ApGltn sealant in comparison with a fibrin sealant using a new spray system in ex vivo and in vivo models. METHODS Pleural defects in ex vivo and in vivo porcine models were created, to which the ApGltn sealant or the fibrin sealant was applied. The pressure resistance was assessed with a stepwise increase in airway pressure to confirm air leakage from the sealing site. Tissue samples covered with each sealant were obtained for histologic assessment. RESULTS In the ex vivo experiment, the leak pressures of the ApGltn sealant were significantly greater than those of the fibrin sealant (102.94 ± 15.6 cmH2O and 28.37 ± 5.1 cmH2O, respectively) (p < 0.01). In the in vivo experiment, the leak pressures of the ApGltn sealant were also significantly greater than those of the fibrin sealant (68.82 ± 18.04 cmH2O and 43.33 ± 7.13 cmH2O, respectively) (p = 0.043). The histologic examination confirmed that the ApGltn sealant adhered tightly to both the pleura and the surface of the pleural defect. CONCLUSIONS The ApGltn sealant has sufficiently high adhesive quality in ex vivo and in vivo porcine lungs, which could be considered suitable and effective for use in the prevention of air leakage from the lungs.
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Affiliation(s)
- Takahiro Yanagihara
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Naoki Maki
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - A I Wijesinghe
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Shoko Sato
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yusuke Saeki
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Shinsuke Kitazawa
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Masatoshi Yamaoka
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Naohiro Kobayashi
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Shinji Kikuchi
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Yukinobu Goto
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Hideo Ichimura
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan
| | - Shiharu Watnabe
- National Institute for Materials Science, Research Center for Functional Materials, Polymer-Bio Field, 1-1 Namiki, Tsukuba, Ibaraki, Japan
| | - Tetsushi Taguchi
- National Institute for Materials Science, Research Center for Functional Materials, Polymer-Bio Field, 1-1 Namiki, Tsukuba, Ibaraki, Japan
| | - Yukio Sato
- University of Tsukuba, Faculty of Medicine, Department of Thoracic Surgery, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan.
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5
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Postoperative complications of pulmonary resection. Clin Radiol 2020; 75:876.e1-876.e15. [PMID: 32600652 DOI: 10.1016/j.crad.2020.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 05/06/2020] [Indexed: 12/25/2022]
Abstract
Thoracic surgery has seen a resurgence in recent years with increasing numbers of cases taken on since the mid-2000s. There has been a paradigm shift in how we manage lung cancer with more emphasis on surgical resection, and this has been aided by minimally invasive video-assisted thoracic surgery (VATS) techniques. As a result, the prevalence of postoperative findings and complications is also increasing, and it is increasingly important for the general radiologist to recognise and diagnose these conditions as thoracic surgical patients may present acutely to non-thoracic surgical institutions. This review will cover both the early and late complications following a variety of lung resection surgeries.
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6
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Prediction of prolonged air leak after lung resection using continuous log data of flow by digital drainage system. Gen Thorac Cardiovasc Surg 2019; 67:684-689. [DOI: 10.1007/s11748-019-01073-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 01/11/2019] [Indexed: 11/25/2022]
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7
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Mortman KD, Corral M, Zhang X, Berhane I, Soleas IM, Ferko NC. Length of stay and hospitalization costs for patients undergoing lung surgery with Progel pleural air leak sealant. J Med Econ 2018; 21:1016-1022. [PMID: 29999435 DOI: 10.1080/13696998.2018.1499519] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIM Progel Pleural Air Leak Sealant (Progel) is currently the only sealant approved by the FDA for the treatment of air leaks during lung surgery. This study was performed to determine whether Progel use improves hospital length of stay (LOS) and hospitalization costs compared with other synthetic/fibrin sealants in patients undergoing lung surgery. METHODS The US Premier hospital database was used to identify lung surgery discharges from January 1, 2010 to June 30, 2015. Eligible discharges were categorized as "Progel Sealant" or "other sealants" using hospital billing data. Propensity score matching (PSM) was performed to control for hospital and patient differences between study groups. Primary outcomes were hospital LOS and all-cause hospitalization costs. Clinical outcomes, hospital re-admissions, and sealant product use were also described. RESULTS After PSM, a total of 2,670 discharges were included in each study group; baseline characteristics were balanced between groups. The hospital LOS (mean days ± standard deviation, median) was significantly shorter for the Progel group (9.9 ± 9.6, 7.0) compared with the other sealants group (11.3 ± 12.8, 8.0; p < .001). Patients receiving Progel incurred significantly lower all-cause hospitalization costs ($31,954 ± $29,696, $23,904) compared with patients receiving other sealants ($36,147 ± $42,888, $24,702; p < .001). LIMITATIONS It is not possible to say that sealant type alone was responsible for the findings of this study, and analysis was restricted to the data available in the Premier database. CONCLUSIONS Among hospital discharges for lung surgery, Progel use was associated with significantly shorter hospital LOS and lower hospitalization costs compared with other synthetic/fibrin sealants, without compromising clinical outcomes.
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Affiliation(s)
- Keith D Mortman
- a Division of Thoracic Surgery , The George Washington University Hospital , Washington , DC , USA
| | | | | | | | - Ireena M Soleas
- c Cornerstone Research Group Inc. , Burlington , ON , Canada
| | - Nicole C Ferko
- c Cornerstone Research Group Inc. , Burlington , ON , Canada
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8
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Kronborg-White S, Ravaglia C, Dubini A, Piciucchi S, Tomassetti S, Bendstrup E, Poletti V. Cryobiopsies are diagnostic in Pleuroparenchymal and Airway-centered Fibroelastosis. Respir Res 2018; 19:135. [PMID: 30005615 PMCID: PMC6045856 DOI: 10.1186/s12931-018-0839-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/02/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibroelastosis (iPPFE) is a rare lung lesion characterized by pleural and subpleural parenchymal thickening due to accumulation of fibroelastotic tissue. Only recently, a few cases with a peribronchiolar distribution of fibroelastotic tissue have been reported. These lesions are more prominent in the upper lobes. Even though high resolution computed tomography (HRCT) scan features are considered characteristic, a histological confirmation is suggested, mainly when the clinical setting is not clearly defined. However, due to non-negligible complications, a surgical lung biopsy is not often recommended. The prognosis is usually poor and currently, the only effective treatment is lung transplantation. METHOD Patients with a multidisciplinary diagnosis of iPPFE or airway-centered fibroelastosis (airway-centered FE), with histological confirmation by transbronchial cryobiopsy, were identified from an ongoing interstitial lung disease registry. Data on patient demographics, HRCT patterns, size and number of biopsies, histology patterns and complications were registered. RESULTS Seven patients were diagnosed with iPPFE and one patient was diagnosed with airway-centered FE. Pneumothorax was documented in three cases, but none of them required a chest tube. No other complications during or after the procedure were observed. CONCLUSION This study suggests that using cryobiopsies in the diagnostics of PPFE and airway-centered FE is safe and effective.
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Affiliation(s)
- Sissel Kronborg-White
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark.
| | - Claudia Ravaglia
- Department of the Diseases of the Thorax, Ospedale Morgagni, Forli, Italy
| | | | - Sara Piciucchi
- Department of Radiology, Ospedale Morgagni, Forli, Italy
| | - Sara Tomassetti
- Department of the Diseases of the Thorax, Ospedale Morgagni, Forli, Italy
| | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Venerino Poletti
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark.,Department of the Diseases of the Thorax, Ospedale Morgagni, Forli, Italy
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9
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10
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Yoo A, Ghosh SK, Danker W, Kassis E, Kalsekar I. Burden of air leak complications in thoracic surgery estimated using a national hospital billing database. CLINICOECONOMICS AND OUTCOMES RESEARCH 2017; 9:373-383. [PMID: 28721079 PMCID: PMC5498775 DOI: 10.2147/ceor.s133830] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background One of the most common outcomes of lung resections are parenchymal air leaks. These air leaks are most often self-limited and spontaneously resolve several days after surgery. Historically, only prolonged air leaks have been considered to have a significant effect on patient outcomes. This study aims to evaluate the impact of any air leak complications (aALCs) on resource utilization and mortality. Methods The Premier Perspective® database was used to identify all elective primary lobectomy, segmentectomy, and wedge resections performed from 2012 to 2014; aALC was defined as a composite of air leak and pneumothorax. Generalized estimating equation models were used to estimate the impact of aALCs on length of stay (LOS), operating room time (ORT), hospital costs, and mortality during index hospitalization. Results A total of 21,150 patients undergoing lung resection surgery were included in the analysis: lobectomy (n=10,946), segmentectomy (n=1,788), and wedge resection (n=8,416). The overall incidence of aALCs was 24.26% (95% CI [23.68, 24.83]). Identified risk factors included resection type, surgical approach, male gender, and presence of COPD. Patients with aALCs had a significantly higher economic burden (adjusted mean [standard error of mean, SE]: LOS=7.24 [SE=0.12] days; ORT=214.9 [SE=6.4] min; and hospital costs=$26,070 [SE=$1404]) compared to those without aALCs (adjusted mean [SE]: LOS=4.75 [SE=0.07] days; ORT=201.7 [SE=3.9] min; and hospital costs=$19,558 [SE=$399]). aALC was also associated with increased overall index hospitalization mortality (odds ratio=1.90, 95% CI [1.42, 2.55]). Conclusion This analysis showed that aALCs are not only frequent but also associated with significantly higher resource utilization and mortality.
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Affiliation(s)
- Andrew Yoo
- Medical Devices - Epidemiology, Johnson and Johnson, New Brunswick
| | - Sudip K Ghosh
- Global Health Economics and Market Access, Ethicon Inc., Somerville, NJ
| | - Walter Danker
- Global Health Economics and Market Access, Ethicon Inc., Somerville, NJ
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Brunelli A, Salati M, Pompili C, Gentili P, Sabbatini A. Intraoperative air leak measured after lobectomy is associated with postoperative duration of air leak. Eur J Cardiothorac Surg 2017; 52:963-968. [DOI: 10.1093/ejcts/ezx105] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/15/2017] [Indexed: 11/12/2022] Open
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12
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Okada S, Shimada J, Kato D, Tsunezuka H, Inoue M. Prolonged air leak following lobectomy can be predicted in lung cancer patients. Surg Today 2017; 47:973-979. [PMID: 28091813 DOI: 10.1007/s00595-016-1467-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/05/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to identify the factors associated with prolonged air leak (PAL) following pulmonary lobectomy for lung cancer. METHODS The data of 146 patients who underwent pulmonary lobectomy for lung cancer between August 2010 and July 2015 were retrospectively reviewed. Air leaks were assessed daily by a visual evaluation and were categorized as follows: forced expiratory only (Grade 1), expiratory only (Grade 2), or continuous (Grade 3). Logistic regression analyses were performed to identify the predictors of PAL (>5 days). RESULTS PAL occurred in 23 patients (16%). An air leak at rest (Grade ≥ 2) was detected on postoperative day (POD) 1 in 48% of the patients with PAL and 7% of the patients without PAL. A univariate analysis demonstrated that PAL was significantly associated with male sex, a smoking history of ≥ 40 pack years, a serum albumin level of ≤4.0 mg/dL, and an air leak on POD1 (Grade ≥ 2). A multivariate analysis demonstrated that a serum albumin level of ≤4.0 mg/dL (p = 0.027) and an air leak on POD1 (p = 0.006) were independent predictors of PAL. PAL occurred in 75% of the patients with these two risk factors. CONCLUSIONS The preoperative serum albumin level and the presence of a visually evaluated air leak on POD1 may be useful indicators for the perioperative management of air leaks.
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Affiliation(s)
- Satoru Okada
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Junichi Shimada
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Daishiro Kato
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Hiroaki Tsunezuka
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Masayoshi Inoue
- Division of Thoracic Surgery, Department of Surgery, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajiicho, Kawaramachidori-Hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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13
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Wood DE, Lauer LM, Layton A, Tong KB. Prolonged length of stay associated with air leak following pulmonary resection has a negative impact on hospital margin. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:187-95. [PMID: 27274293 PMCID: PMC4876678 DOI: 10.2147/ceor.s95603] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Protracted hospitalizations due to air leaks following lung resections are a significant source of morbidity and prolonged hospital length of stay (LOS), with potentially significant impact on hospital margins. This study aimed to evaluate the relationship between air leaks, LOS, and financial outcomes among discharges following lung resections. Materials and methods The Medicare Provider Analysis and Review file for fiscal year 2012 was utilized to identify inpatient hospital discharges that recorded International Classification of Diseases (ICD-9) procedure codes for lobectomy, segmentectomy, and lung volume reduction surgery (n=21,717). Discharges coded with postoperative air leaks (ICD-9-CM codes 512.2 and 512.84) were defined as the air leak diagnosis group (n=2,947), then subcategorized by LOS: 1) <7 days; 2) 7–10 days; and 3) ≥11 days. Median hospital charges, costs, payments, and payment-to-cost ratios were compared between non-air leak and air leak groups, and across LOS subcategories. Results For identified patients, hospital charges, costs, and payments were significantly greater among patients with air leak diagnoses compared to patients without (P<0.001). Hospital charges and costs increased substantially with prolonged LOS, but were not matched by a proportionate increase in hospital payments. Patients with LOS <7, 7–10, and ≥11 days had median hospital charges of US $57,129, $73,572, and $115,623, and costs of $17,594, $21,711, and $33,786, respectively. Hospital payment increases were substantially lower at $16,494, $16,307, and $19,337, respectively. The payment-to-cost ratio significantly lowered with each LOS increase (P<0.001). Higher inpatient hospital mortality was observed among the LOS ≥11 days subgroup compared with the LOS <11 days subgroup (P<0.001). Conclusion Patients who develop prolonged air leaks after lobectomy, segmentectomy, or lung volume reduction surgery have the best clinical and financial outcomes. Hospitals experience markedly lower payment-to-cost ratios as LOS increases. Interventions minimizing air leak or allowing outpatient management will improve financial performance and hospital margins for lung surgery.
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Affiliation(s)
- Douglas E Wood
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, USA
| | | | | | - Kuo B Tong
- Quorum Consulting, Inc., San Francisco, CA, USA
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14
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Bintcliffe OJ, Hallifax RJ, Edey A, Feller-Kopman D, Lee YCG, Marquette CH, Tschopp JM, West D, Rahman NM, Maskell NA. Spontaneous pneumothorax: time to rethink management? THE LANCET. RESPIRATORY MEDICINE 2015; 3:578-88. [PMID: 26170077 DOI: 10.1016/s2213-2600(15)00220-9] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 05/14/2015] [Accepted: 05/19/2015] [Indexed: 11/16/2022]
Abstract
There are substantial differences in international guidelines for the management of pneumothorax and much geographical variation in clinical practice. These discrepancies have, in part, been driven by a paucity of high-quality evidence. Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having primary spontaneous pneumothorax, a group in whom recommended management differs from those with clinically apparent lung disease. Pathophysiological mechanisms underlying pneumothorax are now better understood and this may have implications for clinical management. Risk stratification of patients at baseline could help to identify subgroups at higher risk of recurrent pneumothorax who would benefit from early intervention to prevent recurrence. Further research into the roles of conservative management, Heimlich valves, digital air-leak monitoring, and pleurodesis at first presentation might lead to an increase in their use in the future.
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Affiliation(s)
- Oliver J Bintcliffe
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine and Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Anthony Edey
- Department of Radiology, North Bristol NHS Trust, Bristol, UK
| | | | - Y C Gary Lee
- Centre for Asthma, Allergy and Respiratory Research, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | | | | | | | - Najib M Rahman
- Oxford Centre for Respiratory Medicine and Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, UK.
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15
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Watanabe S, Waseda Y, Takato H, Matsunuma R, Johkoh T, Egashira R, Kawabata Y, Ikeda H, Yasui M, Fujimura M, Kasahara K. Pleuroparenchymal fibroelastosis: Distinct pulmonary physiological features in nine patients. Respir Investig 2015; 53:149-155. [PMID: 26100174 DOI: 10.1016/j.resinv.2015.02.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/16/2015] [Accepted: 02/08/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND Pleuroparenchymal fibroelastosis (PPFE) is a rare idiopathic interstitial pneumonia defined by pleural and subpleural parenchymal fibrosis predominantly in the upper lobes. Although the radiological and pathological characteristics of PPFE have become increasingly recognized, its pulmonary physiological features are not well understood. METHODS We reviewed nine patients with radiologically and histologically proven PPFE, and evaluated pulmonary physiological data. RESULTS Of the nine patients, six were male and three were female. The median age at presentation was 61 years. Common symptoms were dyspnea on exertion, weight loss, and nonproductive cough. Recurrent pneumothorax was found in eight patients and pneumonia in four. Median pulmonary function test results were as follows: forced vital capacity, 55.4% predicted; total lung capacity (TLC), 67.1% predicted; residual volume (RV), 102.3% predicted; and RV/TLC, 143.6% predicted. RV/TLC was increased without evidence of small airway disease according to clinico-radiologic-pathologic evaluation. The median partial pressure of oxygen in arterial blood and the alveolar-arterial gradient of oxygen were within normal limits, although there was a slightly elevated partial pressure of carbon dioxide in arterial blood (PaCO2). PPFE progressed in all patients despite treatment with pirfenidone, corticosteroids, and immunosuppressive agents. Seven patients died during the follow-up, five because of hypercapnic respiratory failure. CONCLUSIONS PPFE is characterized by severe mechanical restriction with high RV/TLC, causing increased PaCO2 and eventual hypercapnic respiratory failure. These physiological findings may be useful as an adjunct in the diagnosis of PPFE.
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Affiliation(s)
- Satoshi Watanabe
- Department of Respiratory Medicine, Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
| | - Yuko Waseda
- Department of Respiratory Medicine, Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa 920-8641, Japan; Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Waehringer Guertel 18-20, Vienna 1090 Austria.
| | - Hazuki Takato
- Department of Respiratory Medicine, Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
| | - Ryo Matsunuma
- Department of Respiratory Medicine, Komatsu Municipal Hospital, Ho-60, Mukaimoto-ori-machi, Komatsu 923-8560, Japan.
| | - Takeshi Johkoh
- Department of Radiology, Kinki Central Hospital of Mutual Aid Association of Public School Teachers, 3-1 Kurumazuka, Itami, Hyogo 664-8533, Japan.
| | - Ryoko Egashira
- Department of Radiology, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan.
| | - Yoshinori Kawabata
- Division of Diagnostic Pathology, Saitama Prefectural Cardiovascular and Respiratory Center, 1696 Itai, Kumagaya City, Saitama 360-0105, Japan.
| | - Hiroko Ikeda
- Section of Diagnostic Pathology, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
| | - Masahide Yasui
- Department of Respiratory Medicine, Kanazawa Municipal Hospital, 3-7-3, Heiwa-machi, Kanazawa, Ishikawa 921-8105, Japan.
| | - Masaki Fujimura
- Department of Respiratory Medicine, National Hospital Organization Nanao Hospital, 3-1, Mattoumachi-hachibu, Nanao, Ishikawa, Japan.
| | - Kazuo Kasahara
- Department of Respiratory Medicine, Cellular Transplantation Biology, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa 920-8641, Japan.
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Mueller MR, Marzluf BA. The anticipation and management of air leaks and residual spaces post lung resection. J Thorac Dis 2014; 6:271-84. [PMID: 24624291 DOI: 10.3978/j.issn.2072-1439.2013.11.29] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 11/27/2013] [Indexed: 11/14/2022]
Abstract
The incidence of any kind of air leaks after lung resections is reportedly around 50% of patients. The majority of these leaks doesn't require any specific intervention and ceases within a few hours or days. The recent literature defines a prolonged air leak (PAL) as an air leak lasting beyond postoperative day 5. PAL is associated with a generally worse outcome with a more complicated postoperative course anxd prolonged hospital stay and increased costs. Some authors therefore consider any PAL as surgical complication. PAL is the most prevalent postoperative complication following lung resection and the most important determinant of postoperative length of hospital stay. A low predicted postoperative forced expiratory volume in 1 second (ppoFEV1) and upper lobe disease have been identified as significant risk factors involved in developing air leaks. Infectious conditions have also been reported to increase the risk of PAL. In contrast to the problem of PAL, there is only limited information from the literature regarding apical spaces after lung resection, probably because this common finding rarely leads to clinical consequences. This article addresses the pathogenesis of PAL and apical spaces, their prediction, prevention and treatment with a special focus on surgery for infectious conditions. Different predictive models to identify patients at higher risk for the development of PAL are provided. The discussion of surgical treatment options includes the use of pneumoperitoneum, blood patch, intrabronchial valves (IBV) and the flutter valve, and addresses the old question, whether or not to apply suction to chest tubes. The discussed prophylactic armentarium comprises of pleural tenting, prophylactic intraoperative pneumoperitoneum, sealing of the lung, buttressing of staple lines, capitonnage after resection of hydatid cysts, and plastic surgical options.
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Affiliation(s)
- Michael Rolf Mueller
- Otto Wagner Hospital, Department of Thoracic Surgery, Baumgartner Hoehe 1, A-1145 Vienna, Austria
| | - Beatrice A Marzluf
- Otto Wagner Hospital, Department of Thoracic Surgery, Baumgartner Hoehe 1, A-1145 Vienna, Austria
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17
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Kanzaki R, Inoue M, Minami M, Shintani Y, Nakagiri T, Funaki S, Kogo M, Yura Y, Inohara H, Sawabata N, Okumura M. Surgery for pulmonary malignancies in patients with a previous history of head and neck squamous cell carcinoma. Surg Today 2013; 44:646-52. [PMID: 23589058 DOI: 10.1007/s00595-013-0593-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 01/23/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE To examine the perioperative and long-term outcomes of surgery for malignancies of the lungs in patients with a history of head and neck squamous cell carcinoma (HNSCC) and to evaluate the risk factors associated with postoperative complications. METHODS The data of 39 patients with a history of HNSCC who underwent pulmonary resection were reviewed. The perioperative and long-term outcomes were analyzed. RESULTS Eight patients (21%) had difficult airways, and nine patients (23%) developed postoperative complications. A low body mass index (<18.5), a history of malignancy besides HNSCC and chronic obstructive pulmonary disease were each found to be significantly associated with the development of postoperative complications. The 5-year survival rate of all patients was 80%. CONCLUSIONS The airway management of patients with a history of HNSCC should be carefully undertaken. Preoperative assessment of their nutritional status and careful prevention of air leakage during surgery are important. Because favorable outcomes can be achieved, aggressive surgical management should be considered for the treatment of pulmonary malignancies in patients with a history of HNSCC.
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Affiliation(s)
- Ryu Kanzaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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