Persistent Air Leak

Dwi Anggita, Edward Pandu Wiriansya, Arif Santoso, Harry Azka Putrawan


In cases of pneumothorax in the chest tube, the presence of air in the pleural cavity that lasts more than 5 to 7 days can be suspected as a persistent air leak (PAL), especially if an increased amount of air is obtained accompanied by the appearance of bubbles in the water seal drainage (WSD) system. This is the most common complication after surgery (8–26%), although it can be primary spontaneous pneumothorax (PSP) (26%) or secondary spontaneous pneumothorax (SSP) (39%). One condition that often causes difficulties in PAL therapy is infection due to direct contact with the fistula. The presence of PAL is associated with higher morbidity and mortality, prolonged chest tube inserted, and longer hospitalization. Observations of air production in PAL are expected to occur spontaneously within 4 days, if the leak persists, pleurodesis is recommended. If it was possible, surgery is needed to close the leak. Bronchoscopy treatment is only recommended in special circumstances where surgery is contraindicated or the patient refuses the surgical procedure.


alveolar-pleural fistula, bronchopleural fistula, persistent air leak

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Sakata KK, Reisenauer JS, Kern RM, Mullon JJ. Persistent air leak-review. Respir Med. 2018;137:213–8.

Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of persistent air leaks. Chest. 2017;152(2):417–23.

Hoeijmakers F, Hartemink KJ, Verhagen AF, Steup WH, Marra E, Röell WFB, et al. Variation in incidence, prevention and treatment of persistent air leak after lung cancer surgery. European Journal of Cardio-Thoracic Surgery. 2022;61(1):110–7.

Okuda M, Go T, Yokomise H. Risk factor of bronchopleural fistula after general thoracic surgery. Gen Thorac Cardiovasc Surg. 2017;65(12):679–85.

Batıhan G, Can CK. Bronchopleural fistula: causes, diagnoses and management. Dis Pleura. 2020;1–14.

Walker SP, Hallifax R, Rahman NM, Maskell NA. Challenging the paradigm of persistent air leak: are we prolonging the problem? Am J Respir Crit Care Med. 2022;206(2):145–9.

Mentzer SJ, Tsuda A, Loring SH. Pleural mechanics and the pathophysiology of air leaks. J Thorac Cardiovasc Surg. 2018;155(5):2182–9.

Jiang L, Jiang G, Zhu Y, Hao W, Zhang L. Risk factors predisposing to prolonged air leak after video-assisted thoracoscopic surgery for spontaneous pneumothorax. Ann Thorac Surg. 2014;97(3):1008–13.

DeCamp MM, Blackstone EH, Naunheim KS, Krasna MJ, Wood DE, Meli YM, et al. Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial. Ann Thorac Surg. 2006;82(1):197–207.

Kurman JS, Hogarth DK. Minimally invasive persistent air leak management. AME Med J. 2018;3:80.

Shekar K, Foot C, Fraser J, Ziegenfuss M, Hopkins P, Windsor M. Bronchopleural fistula: an update for intensivists. J Crit Care. 2010;25(1):47–55.

Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest. 2005;128(6):3955–65.

Sarkar P, Chandak T, Shah R, Talwar A. Diagnosis and management bronchopleural fistula. Indian J Chest Dis Allied Sci. 2010;52(2):97.

Dal Agnol G, Vieira A, Oliveira R, Figueroa PAU. Surgical approaches for bronchopleural fistula. Open Thoracic Surgery. 2017;84.

Sakata KK, Nasim F, Schiavo DN, Nelson DR, Kern RM, Mullon JJ. Methylene blue for bronchopleural fistula localization. J Bronchology Interv Pulmonol. 2018;25(1):63–6.

El-Sameed YA. Role of Bronchoscopy in Management of Bronchopleural Fistula. In: Interventional Bronchoscopy. Springer; 2013. p. 211–25.

Cerfolio RJ, Minnich DJ, Bryant AS. The removal of chest tubes despite an air leak or a pneumothorax. Ann Thorac Surg. 2009;87(6):1690–6.

Gogakos A, Barbetakis N, Lazaridis G, Papaiwannou A, Karavergou A, Lampaki S, et al. Heimlich valve and pneumothorax. Ann Transl Med. 2015;3(4).

Kurman JS. Persistent air leak management in critically ill patients. J Thorac Dis. 2021;13(8):5223.

Hugen N, Hekma EJ, Claessens NJM, Smit HJM, Reijnen MMPJ. Efficacy of an autologous blood patch for prolonged air leak: a systematic review. Ann Thorac Surg. 2022;114(3):1064–71.

How CH, Hsu HH, Chen JS. Chemical pleurodesis for spontaneous pneumothorax. Journal of the Formosan Medical Association. 2013;112(12):749–55.

Liberman M, Muzikansky A, Wright CD, Wain JC, Donahue DM, Allan JS, et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg. 2010;89(3):891–8.

Clark JM, Cooke DT, Brown LM. Management of complications after lung resection: prolonged air leak and bronchopleural fistula. Thorac Surg Clin. 2020;30(3):347–58.

Eberhardt R, Gompelmann D, Herth FJF, Schuhmann M. Endoscopic bronchial valve treatment: patient selection and special considerations. Int J Chron Obstruct Pulmon Dis. 2015;10:2147.



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Jurnal Respirologi Indonesia
pISSN: 0853-7704 - eISSN: 2620-3162
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