Use of autologous blood patch for prolonged air leak in spontaneous pneumothoraces in the adolescent population

Novel Image-Guided Percutaneous Lung Tissue Excision Device With Integrated Sealing of Blood Vessels and Airways: An In Vivo Preclinical Study

OBJECTIVE

This study evaluated the efficacy of the Minimally Invasive Targeted Resection (MiTR) device, a novel electrosurgical instrument that allows for targeted excision of a lung abnormality while using bipolar radiofrequency (RF) energy to seal blood vessels and airways.

METHODS

The MiTR system was evaluated in 7 acute and 2 chronic porcine (7-day) models to evaluate the efficacy of tissue excision with bipolar RF sealing of blood vessels and airways and application of an autologous blood patch into the excised tissue cavity. Air leak was recorded for all evaluations. The study was approved by the institutional ethical board.

RESULTS

Nineteen lung tissue samples, measuring 2.5 cm long × 1.2 cm diameter, were excised. In 8 of 9 animals (89%), hemostasis and pneumostasis were observed visually at the completion of the procedure. In 2 of 2 chronic animals (100%), hemostasis and pneumostasis persisted for the 7-day observation period. Histologic examination of the excised samples showed preservation of the core parenchymal architecture without evident tissue damage of the samples that would impair pathologic analysis.

CONCLUSIONS

Percutaneous resection of targeted lung tissue with the MiTR system demonstrated hemostasis and pneumostasis while obtaining a histologically intact sample. After regulatory approval, the use of this device could offer more tissue for analysis than a transthoracic needle biopsy or bronchoscopy and a far less invasive alternative to video-assisted thoracic surgery or thoracotomy. This may also expand patient and physician options for the early diagnosis and treatment of lung cancer.

The contemporary management of spontaneous pneumothorax in adults

Spontaneous pneumothorax is a common presentation, and there has been a recent surge of research into the condition. With the recent publication of the new British Thoracic Society guidelines and the upcoming European Respiratory Society guidelines, we provide a concise up-to-date summary of clinical learning points. In particular we focus on the role of conservative or ambulatory management, as well as treatment options for persistent air leak and guidance for when to refer to thoracic surgeons for the prevention of the recurrence of pneumothorax.

Educational aims

To give up-to-date guidance on the acute management of spontaneous pneumothorax, including the role of conservative or ambulatory managementTo discuss the different treatment options for persistent air leak.To guide physicians on when to refer patients to thoracic surgeons for the prevention of the recurrence of pneumothorax.

A step-up approach to management of complex bronchopleural fistula

Bronchopleural fistula (BPF) is a sinus tract between a mainstem, lobar or segmental bronchus and the pleural space. We present a 68-year-old male with a 13 mm spiculated left lower lobe nodule who underwent video-assisted thoracoscopic surgery left lower lobe wedge resection followed by persistent BPF requiring open window thoracostomy. We present a step-up approach to management of persistent BPF with discussion of conservative, operative and reconstructive techniques for closure.

Application of autologous blood patch in patients with non-expanded lungs and persistent air leak

Background

This study aims to evaluate the effectiveness of pleurodesis procedure by ensuring the expansion of the lung and occluding lung parenchyma leaks with an autologous blood patch.

Methods

A total of 24 patients (17 males, 7 females; mean age 59.9±12.2 years; range, 30 to 86 years) who underwent autologous blood patch pleurodesis in our clinic between November 2015 and November 2019 were retrospectively analyzed. The patients were not eligible to undergo chemical pleurodesis due to a nonexpandable lung or poor general condition. Demographic and clinical characteristics of the patients and postoperative data were evaluated.

Results

The air leak stopped within 48 h after autologous blood patch pleurodesis in seven patients. The air leak significantly decreased in 13 patients, while it remained unchanged in four patients. A Heimlich valve was placed in the patients in whom the air leak stopped or significantly decreased. The follow-up chest X-rays showed that the respective lungs of these patients became completely expandable.

Conclusion

Our study results suggest that the autologous blood patch procedure is a favorable option for the patients who are unable to benefit much from the conventional chemical pleurodesis methods due to contraindications to surgery or the presence of non-expandable lungs.

The effectiveness of blood amount used in pleurodesis to prevent prolonged air leakage

Background

This study aims to investigate the effects of different amounts of blood used in autologous blood patch pleurodesis on clinical outcomes in patients with secondary spontaneous pneumothorax.

Methods

Between January 2015 and April 2019, a total of 42 patients (36 males, 6 females; mean age 52.1±16.0 years; range, 25 to 83 years) with SSP treated in our clinic with persistent air leakage for more than seven days were retrospectively analyzed. The patients were divided into two groups as receiving 60 mL autologous blood patch pleurodesis (Group 1, n=20) and 120 mL autologous blood patch pleurodesis (Group 2, n=22). Data including age, gender, operation side, complications, recurrence rates, time to tube withdrawal, and length of hospital stay were recorded and compared between the groups.

Results

The mean duration of air leakage was 3.3±2.4 (range, 1 to 11) days, the mean number of pleurodesis was 1.6±0.7 (range, 1 to 3), the mean time to tube withdrawal was 5.2±3.3 (range, 1 to 16) days, the mean length of hospitalization was 7.1±3.6 (range, 3 to 18) days. There were statistically significant differences in all variables analyzed between Group 1 and Group 2 (p<0.001).

Conclusion

Autologous blood patch pleurodesis is an effective and safe method in the treatment of prolonged air leakage in secondary spontaneous pneumothorax. In addition, 120 mL of blood seems to be more effective option for pleurodesis.

A Case of Persistent Air Leak Managed by Selective Left Main Bronchus Intubation in an Infant with Pulmonary Tuberculosis

BACKGROUND Persistent air leak, or persistent pneumothorax, is defined as a pneumothorax that persists beyond the first week, or air leak through a chest drain for more than 48 hours. The most common findings in pediatric pulmonary tuberculosis are parenchymal disease and mediastinal lymphadenopathy, but airway obstruction can cause emphysema and pneumothorax. A case is presented of persistent air leak in a 3-month-old infant with pulmonary tuberculosis that was managed by selective left main bronchus intubation. CASE REPORT A 3-month-old boy presented with respiratory distress and fever. Imaging findings suggested pulmonary tuberculosis, and first-line anti-tuberculous treatment was initiated with isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE). He was discharged home after eight days, but was admitted four days later with respiratory distress. Chest X-rays showed a tension pneumothorax that required drainage and chest computed tomography (CT) showed right lung emphysema. Bronchoscopy found extrinsic obstruction of both main bronchi. Chest drains continued to leak air leak after 48 h. Right middle and lower lobectomy and drainage of multiple lymph nodes resulted in significant improvement. He developed pneumonia and acute respiratory distress syndrome, which prevented mechanical ventilation. The left main bronchus was selectively intubated to allow the air leak to heal and to ventilate the lung. He was extubated 10 days later and recovered completely. CONCLUSIONS This case highlights that when medical management of persistent air leak associated with tuberculosis is not effective, surgery, active ventilation, and selective main bronchus intubation should be considered.