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Doi:10.1016/j.jtcvs.2006.05.033

Autologous blood patch in persistent air leaks after pulmonary resection
Andrea Droghetti, Andrea Schiavini, Piergiorgio Muriana, Andrea Comel, Giuseppe De Donno, Massimiliano Beccaria, Barbara Canneto, Carlo Sturani and Giovanni The online version of this article, along with updated information and services, is The Journal of Thoracic and Cardiovascular Surgery is the official publication of the AmericanAssociation for Thoracic Surgery and the Western Thoracic Surgical Association. Copyright 2006 American Association for Thoracic Surgery General Thoracic Surgery
Droghetti et al
Autologous blood patch in persistent air leaks after
pulmonary resection

Andrea Droghetti, MD,a Andrea Schiavini, MD,a Piergiorgio Muriana, MS,a Andrea Comel, MD,bGiuseppe De Donno, MD,b Massimiliano Beccaria, MD,b Barbara Canneto, MD,a Carlo Sturani, MD,b andGiovanni Muriana, MDa Objective: Persistent air leak is among the most common complications after
pulmonary resection, leading to prolonged hospitalization and increased costs. At
present there is not yet a consensus on their treatment.
Methods: During a 7-year experience, 21 patients submitted to pulmonary resection
were postoperatively treated with an autologous blood patch for persistent air leaks.
Persistent air leaks were catalogued twice daily according to the classificationpreviously reported by Cerfolio and associates. Chest radiographs showed a fixedpleural space deficit in 18 (86%) patients. A total of 50 to 150 mL of autologousblood was drawn from the patient and injected into the chest tube, which wasremoved 48 hours after cessation of the air leak.
Results: We observed a 4% incidence of persistent air leaks after pulmonary
resection in our series. Persistent air leaks were categorized as follows: 14% forced
expiratory, 57% expiratory, 29% continuous, and 0% inspiratory. The mean dura-
tion of prolonged air leaks was 11 days after surgery. In 81% of the cases examined,a blood patch was only carried out once and gave successful results within 24 hours.
In the remaining 19% of cases, the air leak ceased within 12 hours after the secondprocedure. Mean hospital stay was 15 days. In our experience this procedure had a100% success rate.
Conclusions: Pleurodesis with an autologous blood patch is well tolerated, safe, and
inexpensive. This procedure is an effective technique for treatment of postoperative
persistent air leaks, even in the presence of an associated fixed pleural space deficit.
Persistentairleak(PAL),definedasanairleaklastingmorethan7days,is among the most common complications after pulmonary resection, with anincidence of 3% to The resulting prolonged hospitalization has the Pneumology Division and Intensive Re- negative economic effects, delays adjuvant treatment, and may have negative spiratory Unit,b Carlo Poma Hospital, Man- Pleurodesis has been performed by infusion of talc, bacterial components Received for publication April 12, 2006;revisions received May 22, 2006; accepted (OK432), antibiotics (tetracycline, doxycycline), and anticancer agents (mitomycin, adriamycin) with a success rate ranging from 60% to 94%In this article we Address for reprints: Andrea Droghetti, MD, discuss our 7-year experience during which autologous blood patch pleurodesis was adopted as a successful technique in 21 patients with PAL after pulmonary sion, Viale Albertoni 1, 46100 Mantova, Italy(E-mail: ADroghetti@libero.it).
Patients and Methods
Between January 1999 and February 2006, 21 patients (19 men and 2 women) who underwent
Copyright 2006 by The American Asso-ciation for Thoracic Surgery thoracic surgical treatment were submitted to autologous blood patch pleurodesis to treatpersistent air leakage. This allowed us to obtain institutional review board approval to The Journal of Thoracic and Cardiovascular Surgery September 2006
Droghetti et al
General Thoracic Surgery
TABLE 1. Summary of patient data
Abbreviations and Acronyms
Characteristics
The median age at the time of surgery was 67 years (mean 61 years, range 22-83 years). Nineteen (90%) patients had a his- tory of cigarette smoking, 13 (62%) had a past medical diagnosis of emphysema, and 6 (29%) had a history of steroid use (Ͼ10 mg of prednisone per day for at least 1 month before surgical The following operations were performed: pulmonary resection for lung cancer in 14 (67%) patients, decortication for empyema in 2 (10%) patients, and lung volume reduction surgery for emphy- sema in 5 (23%) patients. Thirteen patients with lung cancer underwent lobectomies and 1 patient had a bilobectomy.
Air leaks were catalogued twice daily according to the classi- fication reported by Cerfolio and as expiratory, forced expiratory, inspiratory, or continuous. During the postoperative period, chest physiotherapy and incentive spirometry were carried out on all patients, and bronchodilators were also used when On the basis of results from previous randomized trials, chest tubes were always placed to water seal 48 hours after surgery because this method is more efficient than wall suction for stop- ping air Pneumothorax developed in 18 patients, whose tubes were then replaced on 10 cm H O of wall suction.
An air leak that persisted for more than 7 days was defined as a “prolonged air leak.” As a matter of principle, an autologous blood patch was used for all patients with PAL after 10 postoper- Chest radiographs at the time of pleurodesis showed a fixed pleural space deficit for inadequate expansion capability of the remaining lobe(s) to fill the hemithorax in 18 (85%) patients.
A total of 50 to 150 mL of peripheral venous autologous blood was drawn from the patient and injected into the chest tube (32F) with a 100-mL syringe under aseptic conditions. Blood was not heparinized. No sedation or analgesia was required. The tube was not clamped, but the extension tubing was draped 60 cm over the patient to prevent blood leaving the pleural space but allowing air to be evacuated. The patient’s position on the bed was changed several times during a 1-hour period to help blood distribution into the pleural space. After 6 hours the water seal was reviewed to check for air leak. The next day, a chest radiograph was carried out. In those cases in which the blood patch failed and the air leak continued, the procedure was repeated after 48 hours.
The chest tube was removed 48 hours after cessation of air leak, and in those patients in whom pleural drainage was less than 200mL it was removed after only 24 hours. After chest tube removal, continuous in 6 (29%); no cases of inspiratory air leak were all patients were monitored for clinical and radiologic evidence of recorded. Mean duration of PAL was 11 days after surgery pneumothorax or empyema. All data are reported with medians The lung was completely expanded before application of the blood patch in 3 (14%) patients, 18 (86%) had a fixed pleural space deficit, and 5 (24%) had enlarging subcutane- The incidence of PAL after pulmonary resection in our ous emphysema at the time of pleurodesis.
experience was 4%. The leaks were classified as forced The amount of blood ranged from 50 mL (2 patients, 9%) expiratory in 3 (14%) patients, expiratory in 12 (57%), and to 100 mL (6 patients, 29%) and 150 mL (13 patients, 61%).
The Journal of Thoracic and Cardiovascular Surgery Volume 132, Number 3
General Thoracic Surgery
Droghetti et al
In 17 (81%) patients one injection was sufficient to seal the in short series of PAL after pulmonary resection or sponta- PAL; 4 (19%) patients (2 with 50 mL and 2 with 100 mL) required two injections because the first was not successful.
Our retrospective experience is the largest reported in the The blood patch was carried out once on 17 (81%) literature using this procedure for treating PAL after pul- patients, and within 12 hours no air leak was detected in the monary resection. We observed a success rate of 100% in 21 water seal in 15 (88%) of them; in the other 2 patients success was achieved within 24 hours (mean 15 hours, A bronchoscopy can be warranted to rule out a broncho- median 12 hours, range 6-24 hours). The procedure was pleural fistula that requires different treatment, such as repeated a second time in 4 (19%) patients 48 hours after application of the first blood patch, and air leak ceased Timing to perform blood patch pleurodesis ranges be- within 12 hours. Chest tubes were removed 48 hours after the confirmation of no air leak. One patient was discharged the beginning of our experience we performed blood patch- with a Heimlich valve for prolonged pleural drainage (Ͼ200 ing after 10 days, but later we observed that if an air leak mL per day), which was removed 7 days after pleurodesis.
was present on postoperative day 5 there was a high prob- No pain, respiratory difficulty, cough, or major side effects ability (87% in our series) that it would be present on were observed during the procedure. No significant decrease postoperative day 8 as well, so we proposed to use blood in hematocrit value was observed after removal of blood.
patch pleurodesis after 5 to 7 days to reduce the probability No patient required a reoperation for air leak. No late of pleural infection and to minimize delay of discharge.
empyema or other major morbidity was observed. In 2 Some authors reportedly inject no more than 50 mL of patients submitted to decortication for empyema, low-grade autologous blood to avoid introducing into the pleural space fever lasting 1 day was observed after blood patch pleu- an ideal medium for bacteria that may be complicated by rodesis. One patient had to be transferred to an intensive The first 2 patients were treated by introducing respiratory unit for no invasive positive-pressure ventila- 50 mL of blood, but a second injection was necessary tion. The median hospital stay was 15 days (mean 16 days, because the first procedure did not result in successful range 10-44 days). Follow-up was completed in all patients sealing. Therefore, we subsequently increased to 100 mL of with a median duration of 25 months (range 6-86 months).
blood, and 2 of 6 patients required a second patch. In the last None has had recurrent pneumothorax or empyema. No 13 patients of our series, we introduced 150 mL of blood operative mortality was observed. After 3 months, chest directly with the first patch, and this procedure resulted in a x-ray films confirmed complete re-expansion of the lung complete success rate without any septic complication. We and no pleural drainage in all 21 patients. In no instances in now recommend 150 mL of blood for all patients. Other our experience was this procedure unsuccessful.
authors exclude the use of this treatment in patients whohave air leaks with incomplete lung re-expansion or residual Discussion
pleural space because they fear that blood may represent a The incidence of PAL associated with pneumothorax and culture medium for bacteria with a high risk of empyema causing prolonged hospitalization in patients requiring pul- We want to underline that PAL in itself, even without a blood patch, increases the risk of empyema and that only one expe- Air leak after lobectomy usually ceases spontaneously if rience reports empyema after blood patch pleurodesis—a adequate re-expansion of the remaining lung is established.
Turkish article reporting 3 cases (rate of In our It is frequently treated by prolonged aspiration and use of series, chest radiographs evidenced a fixed pleural space the Heimlich valve, and most authors recommend pleurode- deficit in 18 (86%) patients at the moment of pleurodesis, all sis with sclerosing agents such as tetracycline, talc, or of whom were treated by a blood patch with success and before resorting to a rethoracotomy. However, chemical pleurodesis often fails and PAL with a fixed The sclerosing effect of blood is not as potent as that of pleural space deficit remains. Furthermore, without ade- other agents, but its mechanism may be based on three quate re-expansion, the sclerosing agent itself may prevent factors working together: irritation of pleural surfaces, re- re-expansion of the remaining lung because of thickening of duction of fixed pleural space deficit by clot, and oblitera- tion of alveolar-pleural fistulas by fibrogenic activity and Autologous blood patch pleurodesis has been reported in patch-effect that contribute to re-expansion of the remaining the literature by many authors as a procedure for PAL and pneumothorax with encouraging results. Robinsonwas Williams and Laingreported a case of tension pneu- the first in 1987 to report an 85% success rate with this mothorax after blood patch pleurodesis using 12F (2.6 mm technique in chronic or recurrent spontaneous pneumotho- internal diameter) intercostal catheters. We did not observe races. Subsequently, other authors reported their experience this complication in our series after pulmonary resection, The Journal of Thoracic and Cardiovascular Surgery September 2006
Droghetti et al
General Thoracic Surgery
perhaps because we used only chest tubes with a 32F 8. Keagy BA, Lores ME, Starek PK, Murray GF, Lucas GL. Elective diameter that were not clamped after instillation of blood pulmonary lobectomy: factors associated with morbidity and operativemortality. Ann Thorac Surg. 2002;73:1727-31.
but were raised above the patient, so that occlusion was not 9. Almassi GH, Haasler GB. Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg. 1989;47:786-7.
Blood pleurodesis has low costs, acceptable side effects, 10. Alfageme I, Moreno L, Huertas C, Vargas A, Hernandez J, Beiztegui A. Spontaneous pneumothorax: long-term results with tetracycline and a high rate of success. In our opinion this procedure pleurodesis. Chest. 1994;106:347-50.
should be considered in PAL before a reoperation, in pa- 11. Kennedy L, Rusch VW, Strange C, Ginsberg RJ, Sahn SA. Pleurodesis tients with high risk of surgical morbidity and mortality, and using talc slurry. Chest. 1994;106:342-6.
12. Ishihara K, Hasegawa T, Okazaki M, Katakami N, Sakamoto H, Lee before using other sclerosing agents. The blood patch is also E, et al. OK432 chemical pleurodesis as a standard therapy of spon- effective in those difficult cases in which other sclerosing taneous pneumothorax. Nippon Kyobu Shikkan Gakkai Zasshi. 1988; agents fail, probably because of residual pleural spaces.
13. Cerfolio RJ, Bass C, Katholi CR. A prospective randomized trial Our experience confirms the success obtained with this compares suction versus water seal for air leaks. Ann Thorac Surg. procedure in previous cases as a treatment of PAL after pulmonary resection. We advocate randomized controlled 14. Robinson CL. Autologous blood for pleurodesis in recurrent and chronic spontaneous pneumothorax. Can J Surg. 1987;30:428-9.
trials to ascertain many unclear points of discussion, such as 15. Dumire R, Crabbe MM, Mappin FG, Fontenelle LJ. Autologous selection of patients, right timing, optimal quantity of blood, “blood patch” pleurodesis for persistent pulmonary air leak. Chest. and comparison of results and costs with other procedures.
16. Mallen JK, Landis JN, Frankel KM. Autologous “blood patch” pleu- rodesis for persistent pulmonary air leak. Chest. 1993;103:326-7.
We thank Dr Anna Pierini for her help in preparing the manu- 17. Yokomise H, Satoh K, Ohno N, Tamura K. Autoblood plus OK432 pleurodesis with open drainage for persistent air leak after lobectomy.
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The Journal of Thoracic and Cardiovascular Surgery Volume 132, Number 3
Autologous blood patch in persistent air leaks after pulmonary resection
Andrea Droghetti, Andrea Schiavini, Piergiorgio Muriana, Andrea Comel, Giuseppe De Donno, Massimiliano Beccaria, Barbara Canneto, Carlo Sturani and Giovanni Continuing Medical Education Activities
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