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.
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
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
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“blood patch” pleurodesis. Thorax. 2005;60:1066-7. 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
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