Management of Patients with Prolonged Air Leak after Pulmonary Resection with Heimlich Valve

Prolonged air leak (PAL) after pulmonary resection is de�ned as air leak persisting for �ve or more days. Majority can be managed conservatively using one-way device Heimlich valve (HV) while few may require surgical intervention. Objective: To evaluate safe discharge policy for Prolonged air leak and role of Heimlich valve in its management. Methods: A retrospective study was conducted in the Department of Thoracic surgery at Jinnah Postgraduate Medical Center, Karachi, including patients with PAL following pulmonary resection between the years 2019-2021. Cerfolio Grade IV air leaks were excluded. Results: File records of 467 patients were reviewed; seventy (15%) had PAL. Most common indication for resection was bronchiectasis (n=24; 34.3%); Lobectomy was the most common procedure (31/70; 44.3%) associated with PAL. Grade II (n=38) air leak was most commonly encountered. All grade III patients developed complications (p=0.02), followed by grade II (p=0.07) whereas Grade I had least complications (8/19; p<0.001). Lobectomy patients showed improvement of air leak on HV (p=0.008). Grade I PAL (n=19) discharged on HV had the least frequency of lung collapse (LC) and residual space (RS) (n=8; p=0.006 and n=1; p<0.001) respectively, whereas Grade III (


I N T R O D U C T I O N
Prolonged air leak (PAL) after pulmonary resection is de ned as air leak persisting for ve or more days. Majority can be managed conservatively using one-way device Heimlich valve (HV) while few may require surgical intervention. Objective: To evaluate safe discharge policy for Prolonged air leak and role of Heimlich valve in its management. Methods: A retrospective study was conducted in the Department of Thoracic surgery at Jinnah Postgraduate Medical Center, Karachi, including patients with PAL following pulmonary resection between the years 2019-2021. Cerfolio Grade IV air leaks were excluded. Results: File records of 467 patients were reviewed; seventy (15%) had PAL. Most common indication for resection was bronchiectasis (n=24; 34.3%); Lobectomy was the most common procedure (31/70; 44.3%) associated with PAL. Grade II (n=38) air leak was most commonly encountered. All grade III patients developed complications (p=0.02), followed by grade II (p=0.07) whereas Grade I had least complications (8/19; p<0.001). Lobectomy patients showed improvement of air leak on HV (p=0.008). Grade I PAL (n=19) discharged on HV had the least frequency of lung collapse (LC) and residual space (RS) (n=8; p=0.006 and n=1; p<0.001) respectively, whereas Grade III (n=13) discharged with HV developed signi cant number of complications; LC (n=12;92.8%; p=0.03) and RS (n=11; 84.6%; p<0.001). Conclusions: PAL is an important factor complicating resections. Effective preoperative preparation and meticulous resection technique can decrease complications. Nonetheless, not all patients can be discharged on HV. Patients with smaller leaks can be safely sent home on HV whereas larger leaks require management in hospital with some form of intervention. expansion and is superior to underwater seal alone [10]. This study aims to evaluate the optimum and safe discharge policy in patients with PAL and the role of HV in its management.
A retrospective cross-sectional study was carried out in the Department of Thoracic surgery, Jinnah Postgraduate Medical Center, Karachi from January 2019 to December 2021. It included patients with PAL following pulmonary resection. Ethical approval was attained from Institutional review board committee. PAL was de ned as air leak that can be witnessed clinically for ve days or more following pulmonary resection [4,11]. All patients presenting with benign or malignant parenchymal disease that required any form of pulmonary resection were included. Grade IV air leaks according to Cerfolio classi cation were excluded from this study [12]. Pulmonary resection performed included lobectomy, wedge and segmentectomy. All patients undergoing lobectomy had incomplete ssures. Both hand sewn and stapler technique were employed as no signi cant difference between the two in terms of air leak duration is found in literature [13]. All data that was documented prospectively was collected by three researchers retrospectively, through medical records whereas a separate researchers reviewed the variables. Data variables included age, gender, co-morbid, etiology, procedure type, grade of air leak according to Cerfolio classi cation, duration of air leak, day of application of Heimlich valve®, duration of tube or valve, complications pertaining to Heimlich valve®, need of re intervention or procedure. Common outcomes of patients in uenced the development of research question. SPSS version 22 was utilized for data entry and analysis. Mean and standard deviation was utilized to represent descriptive data such as age, weight, duration of air leak or chest tube, etc. Categorical variables such as gender, disease, etiology, type of resection and others were presented as frequencies and percentages. Independent sample t test was applied for comparison of means; for categorical variables Chi square was utilized. P value ≤0.05 was taken as statistically signi cant.

Disease(n) Lobectomy
Wedge resection  Complications were found in 53 (75.7%) patients who were discharged with HV ( Figure 2      Our review included 70 patients with PAL following pulmonary resection. Bronchiectasis (34.3%) was the leading etiology followed by aspergilloma of lung (21.4%). In literature, PAL incidence after resection was found to be between 8-26% however it varies according to the type of resection; segmentectomy (10-15%), lobectomy (9-13%) and wedge resection (3.3%) [14]. We found PAL incidence of 15% with similar or slightly higher incidence for the different types of resections. Our incidence of PAL with lobectomy was 16% (31/191) as it involved completion of the ssure. Another study also supported higher association of lobectomy with PAL as it involves resection of more pulmonary parenchyma as compared to lesser resections, gravitational effects and a larger residual space [11]. Factors such as COPD and smoking are associated with fragile lung parenchyma causing tobacco induced lung damage, thus lead to reduced healing capacity and PAL [6]. Furthermore, tuberculosis history is strongly correlated with lung scarring and impaired gas exchange ultimately leading to PAL [15]. In our study, diabetes was found in 35 (50%), COPD in 32 (45.7%), tuberculosis history in 25 (35.7%) and 32 (45.7%) patients were smokers. Previous studies have shown adhesions to be an important risk factor for PAL due to parenchymal tears during mobilization of lung [11]. We found adhesions in 64(91.4%) associated with 35(54.68%) developing Grade II air leak. Treatment modalities for PAL range from conservative techniques such as application of Heimlich valve (HV), implantable devices notably tissue adhesives and endobronchial valves, chemical pleurodesis to surgical intervention [15,16]. PAL increases the length of hospital stay and impacts additional cost on healthcare system [15]. Castillo et al. described PAL as the second most common cause of prolonged hospitalization post-lobectomy [15]. In our study, average length of hospital stay was 7.4 ± 1.15 days which was similar to 7.9 days found in another study [4]. HV has shown to be effective for PAL by allowing the lung to heal, residual lung to expand, reduce nosocomial infections, allow patient mobility and manage patients in an outpatient setting [17,18]. HV has proved to be bene cial in lobectomy cases resulting in resolution of PAL [19]. Same was seen in our study, where HV in lobectomy cases with PAL showed improvement of grade of air leak (64.5%, p=0.008) and its resolution in 67.7% cases (p=0.002). Nonetheless, there are certain complications of HV. J.

D I S C U S S I O N
Matthew reported empyema in 16.9% patients when discharged home on HV requiring reoperations in 22.9% [7]. In our review, empyema occurred in 12.9% patients. Most complications were seen in patients undergoing wedge resection (p=0.004) followed by lobectomy (p<0.001) and segmentectomy (p<0.001). Reoperation was mandated in 11.4%, while 37.1% were managed by reinsertion of chest tube attached to suction. The overall readmission rate in our study was 61.4% which is higher than what was observed in previous studies (19.4-26.3%) [4,7]. Aggressive early discharge for PAL with HV attributes to shorten hospitalization and cost bene ts but it is not without consequence [7]. Our primary goal was to establish which grade of PAL can be safely discharged on HV. This study demonstrates that Grade I PAL can be safely discharged home on HV as it has the least frequency of lung collapse (LC) and residual space (RS) (8/19; p<0.006 and 1/19; p<0.001), respectively. Patients with Grade II PAL do not show signi cant values whereas Grade III PAL when discharged with HV developed signi cant complications; LC (92.3%; p<0.03) and RS (84.6%; p<0.001). Duration of air leak> 2 weeks was statistically consistent with complications (p<0.001), of which most common was LC (33/47; p<0.001). Moreover, prolonged use of HV can lead to dysfunction of valve mechanism due to disruption of rubber leading to complications such as tube site leakage, blocked valve, empyema and lung collapse [17]. This was consistent with our ndings; prolonged use of HV> 2weeks led to complications (p<0.001) notably LC (91.4%; p<0.001), RS (89.2%; p<0.008) and tube site leak (71.4%; p<0.001). Patients with bronchiectasis can be safely discharged on HV as complete resolution of PAL was witnessed (p=0.002) when duration of leak did not exceed two weeks (p=0.001). On the other hand, 80% patients with aspergilloma had PAL for more than 2 weeks (p<0.001) and should not be discharged on HV. Considering available data, patients with PAL can be safely discharged with a portable device by Day 4-8 depending on the underlying etiology, procedure performed and grade of air leak [3,20]. However, we attached HV by 5.6 ± 0.88 day and observed for few days before sending home. Our study has certain limitations: It is a single centre, retrospective study with small sample size. However, it does lay grounds for future prospective research on this subject.

C O N C L U S I O N S
PAL after lung resection is a vexing problem faced by thoracic surgeons that increases hospitalization. It can be concluded by our study that patients can be safely sent home on Heimlich valve for Grade I PAL. However, patients with Grade III PAL are more likely to develop complications so they are better to be managed in hospital. A more strategic plan focusing on optimizing preoperative risk