Natural history of residual air spaces after pulmonary resection

It is emphasized that a decision for or against surgical intervention in the management of residual spaces, irrespective of cause, will not be required for several months after their occurrence in most cases. The stresses associated with the critical period of disability occasioned by a prolonged air leak, even if not voluminous, may preclude premature surgical intervention. The indications for initial surgical resection and the diseases for which it was required often are sufficiently debilitating to the patient to produce a protracted period of convalescence, necessitating prolonged observation before a decision for aggressive surgical therapy is mandated or indicated. In our experience, these pleural spaces are not a major threat to the health of the patient. In many cases, the concern over them and the fear that more egregious postoperative problems will ensue have resulted in premature and overzealous treatment that may lead to iatrogenic complications. If, instead, they are left alone and followed with judicious observation based on appropriate clinical, physiologic, and radiologic criteria, a more favorable outcome will result. Haste in arriving at a decision to intervene surgically therefore is not warranted. Many factors must be taken into account before surgical treatment is considered. The age of the patient, his or her ventilatory status, condition of the underlying lung, prospect for physical activity with gainful employment and accompanying quality of life, underlying disease (tuberculosis or cancer) for which even a curative resection may have been done, problems in maintaining drainage (including convenience or discomfort), or adverse metabolic effects of chronic infection are just a few considerations. More recently, economic factors attendant upon managed care programs mandate cost-effective therapies to reduce duration of hospital stay and to decrease resource utilization associated with repetitive surgical procedures and returns to the operating room, protracted use of expensive antimicrobial drugs, and increased outpatient visits and home services. Certainly, prevention of and avoidance of unwarranted interventions for intrathoracic spaces will assist in accomplishing these goals. Finally, it is apparent that patients can live in relatively good health for long periods of time with persisting vented or unvented spaces in association with air leak from alveolar seepage sources, and even with the presence of well-drained and controlled empyemas. The most important aspect of management is delineation of spaces that can be observed safely versus those that require surgical intervention. This discussion provides a basis for making that distinction. The algorithm illustrated in Figure 13 summarizes this management.