Interventional management of persistent pleural air leaks

A persistent air leak (PAL) of the pleura is a condition with a potentially fatal outcome. The development of such bronchopleural or alveolopleural fistulas is associated with a number of risk factors, including but not limited to: -a) Complications arising from larger resection of lung parenchyma; b) Emphysematous disease processes; c) Lower body mass index; d) Extensive infectious diseases, such as tuberculosis and pleural empyema, among others.The primary causes of patient mortality are the occurrence of pulmonary infections and respiratory failure. Subsequent to the localization of the PAL, implementation of timely treatment is indicated. Depending on the patient's location, the size of a PAL, the underlying cause, and the patient's individual characteristics, generally two treatment options are available if the initial placement of a pleural drainage fails to achieve the desired outcome: endoscopic and surgical. Bronchoscopic interventions are defined as the insertion of a chemical or biological sealant, or the placement of a blocking device. Examples of blocking devices include atrial septal defect (ASD) or ventricular septal defect (VSD) occluders, airway stents, endobronchial valves, coils, or endobronchial Watanabe spigots. Further, a variety of surgical options are available for treatment, including the possibility of re-operation if the fistula is based on prior lung resection surgery. Other interventions include suture repair and the placement of flap coverage from various sources. The success of surgical interventions is contingent upon several factors. These include the time between the occurrence of the fistula and the surgical intervention, the fistula size, and the extent of contamination of the ipsilateral pleural cavity or infectious involvement of the contralateral lung. The present review focuses on the effectiveness of various bronchoscopic and surgical measures for the treatment of PALs. It also presents a suggestion of an algorithm in order to rank the different treatment options.