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Eur J Cardiothorac Surg 2004;26:897-900
© 2004 Elsevier Science NL

A prospective study of autologous ‘blood patch’ pleurodesis for persistent air leak after pulmonary resection

Department of Thoracic Surgery, Guy's Hospital, St Thomas Street, London SE1 9RT, UK

Received 27 May 2004; received in revised form 17 July 2004; accepted 23 July 2004.

^* Corresponding author. Tel.: +44-207-188-1038; fax: +44-207-188-1016. (E-mail: loic.lang-lazdunski{at}gstt.nhs.uk).

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 
Objective: To evaluate the efficacy and risks of autologous ‘blood patch’ pleurodesis in patients with persistent air leak after pulmonary resection. Methods: All patients operated on by a single surgeon between January 2002 and January 2004 and presenting with a persistent air leak after pulmonary resection have been treated by the autologous blood patch pleurodesis technique. Fifty millilitres of autologous blood were injected through the chest tube that was then rinsed, clamped for 30min and then unclamped and placed back to water seal. Results: We have obtained a 100% success rate in 11 patients with persistent air leak who have been treated with this technique over a 2-year period. Most air leaks (72.7%) ceased within 12h of blood injection. No patient developed empyema, but two patients developed fever and pleural fluid grew Staphylococcus after blood pleurodesis. At 3-month follow-up, all patients were well and their lungs were expanded fully. Conclusions: In our experience a single injection of 50ml of blood is sufficient to seal persistent air leaks in less than 48h. Although highly effective, the autologous blood patch pleurodesis technique should not be used in patients with incomplete lung re-expansion or positive pleural fluid culture to minimize the risk of empyema.

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 
Persistent air leak remains one of the most common complications after pulmonary resection [1]. It may lead to a longer in-hospital stay and delays effective physiotherapy and rehabilitation due to the pain generated by the chest tube [2]. A persistent air leak can be managed conservatively with a chest drain left in situ and connected to a Heimlich valve [3], or by the injection of irritative substances into the pleural cavity such as tetracycline, quinacrine, talc, or silver nitrate [4]. Recently, some have proposed a more aggressive approach involving re-operation and sealing of the air leak with fibrin glue [5].

Autologous blood was first used by Robinson [6] for treating persistent air leaks in patients with spontaneous pneumothorax. Then, Dumire et al. [7] reported its use after pulmonary lobectomy, with immediate success. Since 1992, there have been very few reports on the beneficial use of autologous blood for sealing persistent air leaks either in patients with spontaneous pneumothorax or after pulmonary resections [8–12].

We have been using autologous ‘blood patch’ pleurodesis for more than 2 years as the only adjunct to seal air leaks in any patients presenting a persistent air leak after pulmonary resection. We describe our experience in 11 consecutive patients treated by a single thoracic surgeon.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 
All patients operated on by a single thoracic surgeon and presenting with a persistent air leak (more than 7 days) after a pulmonary resection received autologous blood patch pleurodesis done after informed consent has been obtained. Chest X-ray was obtained daily after blood pleurodesis and the patient were reviewed in the outpatient clinic after 1 and 3 months.

2.1. Technique
The procedure was carried out on the surgical ward at bedside under aseptic conditions (surgical scrub, mask and sterile gloves), as reported by others [4]. No sedation or special analgesia was used in any patient. Fifty millilitres of peripheral venous blood were taken from the patient's arm. The chest tube (28F in all patients) was clamped and disconnected from the waterseal and its distal end was prepared with povidone–iodine. The blood was immediately injected into the pleural cavity by connecting the cone of a 60ml syringe to the chest tube. The chest tube was then flushed with 10ml of normal saline and the drain was reconnected and clamped for 30min. During this time, the patient was placed in different positions to promote homogeneous distribution of blood into the pleural cavity. Then, the drain was unclamped and placed back on water seal. The waterseal drainage was reviewed every 12h for the presence of an air leak. The chest tube was removed 12h after cessation of air leak and a chest X-ray was obtained after drain removal.

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 
Between January 2002 and January 2004, 196 patients had a lung resection performed by a single surgeon (97 lobectomies, 12 bi-lobectomies and 87 wedge resection). No patient had re-operation for an air leak during that period of time. Two patients (1%) were discharged home with a drain in situ and a Heimlich valve for persitent air leak associated with incomplete lung re-expansion. Eleven patients had a blood patch pleurodesis done for persistent air leak during that period (Table 1). Mean age at operation was 56±15 years (range 31–82 years) and the mean duration of air leak was 7.8±2 days (range 6–11 days, median 7).

Blood pleurodesis was successful in less than 12h in the majority of our patients (8/11, 72.7%) and all patients had the air leak stopped within 48h after the procedure (100%). Median in-hospital stay in this group of patient was 9 days (range 7–16 days). There was no in-hospital mortality and all patients came back for follow-up 3 months after their operation. One patient developed a pneumonia 24h after her blood pleurodesis and was treated with oral antibiotics and two patients developed low-grade fever and microbiological analysis of the pleural fluid revealed Staphylococcus epidermidis (n=1) and Staphylococcus aureus (n=1), both Methicilin-sensitive. The first patient had a left upper lobectomy and chest wall resection for a left Pancoast tumour and was left with a minimal apical air pocket. The second patient had had multiple wedge resections in his right lung for bullous emphysema and had a fully re-expanded lung. Both patients received flucloxacillin for 2 weeks and remained asymptomatic on follow-up. No patient developed a clinically or radiologically significant empyema. There was no occurrence of pneumothorax or subcutaneous emphysema after the drains had been removed. At 3 months, chest X-ray demonstrated re-expanded lungs and no pleural collection in any of the eleven patients.

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 
Persistent air leak remains one of the most common complication of modern thoracic surgery [1]. Rice and Kirby [2] have reported a 15.2% rate of air leak persisting more than 7 days after pulmonary lobectomy in a series of 197 consecutive patients, and others and we have reported a 14.8% rate in 182 patients treated by VATS wedge resection for spontaneous pneumothorax [12]. No technique has proven superiority to others for the treatment of persistent air leak and many thoracic surgeons rely on prolonged drainage in hospital or discharge their patients with a drain in situ and a Heimlich valve, depending upon their patient's preference, functional status and environment [3,4]. Others have used more aggressive approaches to seal the air leak, such as intra-pleural tetracycline, quinacrine, talc [4], creation of a pneumoperitoneum [13], or even re-operation and injection of fibrin glue [5]. Although talc slurry has become very popular among thoracic surgeons, there is still some concern about its theoretical potential serious side effects such as severe pneumonitis or adult respiratory distress syndrome [1].

Autologous blood patch pleurodesis has been first reported by Robinson et al. [6] for the treatment of persistent air leak in patients with spontaneous pneumothorax. He reported a 85% success rate in a series of 25 patients who received 1–3 injections of 50ml of blood in order to seal the air leak [6]. Five years later, Dumire et al. [7] reported the use of that technique in a patient after pulmonary lobectomy. After 5 weeks of unsuccessful drainage and a failed tetracycline pleurodesis, autologous blood sealed the air leak within 2h and the drain was removed, without complication [7]. Recently, Rivas de Andres et al. [4] reported a series of six patients treated with blood patch pleurodesis for persistent air leak after pulmonary resection for primary lung cancer. All air leaks were sealed within 24h of blood injection and there was no procedure-related complication with a mean follow-up of 26 months. Since 1992, the technique has also been reported in short series of patients with spontaneous pneumothorax presenting with persistent air leak [8–11]. In all the series 50–250ml of autologous blood were required, as daily 50ml injection repeated until cessation of air leak [4,6,7–11].

In our experience 50ml of blood have been sufficient in all patients, whereas in a recent series 100–250ml have been necessary to seal the air leak [4]. Most of our patients (72.7%) had cessation of air leak within 12h of blood injection, and all of them by 48h. In the two other surgical series, the air leaks were sealed within 24h of blood injection [4,7]. The reason for not injecting more than 50ml of blood was our concern about injecting an ideal medium for bacteria in a potentially contaminated drain or pleural space. It is likely that drains get colonized with bacteria after the operation, specially in the presence of an alveolar-pleural fistula [14]. Although no patient in our experience developed a clinically significant empyema, two patients did have low-grade fever and pleural fluid grew S. aureus or Staphylococcus epidermidis 24h after the injection of blood. No other series reported any case of empyema, except a Turkish study which reported a 9% rate in patients with spontaneous pneumothorax and persistent air leak [9]. In those cases it is possible that the drains were colonized with bacteria at the time of blood pleurodesis and that blood injection resulted in an experimental inoculation of the pleural cavity. It is therefore worth re-emphasizing the importance of working in a sterile manner with common antiseptics such as povidone–iodine and avoiding blood pleurodesis in patients with incomplete lung re-expansion or persistent post-resection space. In such patients the collection of blood in the pleural cavity may serve as an excellent culture medium for microbes, leading to a real empyema. In addition, repeated manipulation of the drains may increase the risk of bacterial contamination. Therefore, we suggest that autologous blood injection should be performed only once in the form of a 50ml aliquot to limit the risk of empyema. Although we did not routinely perform pleural fluid cultures before performing the blood patch pleurodesis, we estimate that a positive pleural culture represents a contra-indication for using this technique and we suggest that patients have their pleural fluid sent for culture before deciding whether a blood patch pleurodesis should be performed.

One potential complication of the blood patch pleurodesis technique is tension pneumothorax due to blood clotting in the chest tube [11]. We have not observed this complication and are not aware of any case reported in the literature to date. We have flushed the tube with 10ml of normal saline in all patients to prevent this complication. In addition, all our patients were on prophylactic dose of enoxaparin after their operation, making the risk of immediate clotting in the chest tube very low.

The pathophysiological mechanism responsible for the sealing effect of blood is probably multiple. It is likely that blood covers the minimal lacerations in the visceral pleura and pulmonary parenchyma and seals the air leak by a direct mechanical effect (‘patch effect’) [7]. In addition, blood generates an inflammatory reaction in the pleural cavity that may contribute to the adhesion between the parietal and visceral pleurae. By comparison, chemical agents such as tetracycline work only through an inflammatory effect and the air leak does not cease before 3–5 days [15].

Regarding the timing at which blood pleurodesis should be performed, our attitude has been to wait at least 7 days in most patients. However, considering the good results obtained in our first eight patients and the possibility of significant pleural microbial contamination over time, we decided to reduce the time to 6 days in the last three patients. In our experience, most patients that have an air leak after 5 or 6 days are likely to have this air leak persisting at 7 or 9 days. Therefore, we estimate that waiting 7 days to perform a blood patch pleurodesis is just wasting time and delaying patient's discharge. In the literature, the time between the operation and the blood patch pleurodesis has varied from 10 to 23 days in the series reported by Rivas de Andres [4], but has been up to 5 weeks [7].

We suggest that the decision to perform a blood patch pleurodesis should be based on the surgeon's experience, on the result of pleural fluid cultures, on the underlying lung disease and the likelihood of spontaneous air leak cessation, patient's nutritional and functional status and tolerance of prolonged drainage.

We have not performed a cost analysis, but it is clear that the rapid cessation of air leak observed after autologous blood injection may have reduced the length of stay of our patients, which is one of the main factors involved in overall cost. In addition, autologous blood is free and readily accessible, whereas the cost of 10ml of fibrin glue is grossly 480 Euros and the cost of 8g of talc powder is grossly 14 Euros.

	4. Conclusion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 
This short prospective trial demonstrated the effectiveness of autologous blood patch pleurodesis in patients presenting with persistent air leak after pulmonary resection. The method is simple, cheap and effective. Strict adhesion to contra-indications and a single injection of a limited volume of blood (50ml) may minimize the risk of serious infectious complication such as empyema.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion 4. Conclusion References

 

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10. Ando M, Yamamoto M, Kitagawa C, Kumazawa A, Sato M, Shima K, Watanabe A, Shimokata K, Hasegawa Y. Autologous blood patch pleurodesis for secondary spontaneous pneumothorax with persistent air leak. Respir Med 1999;93:432-434.[CrossRef][Medline]
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