Controlling prolonged air leak by remote control

Dr. Gaetano Rocco talks about persistent air leaks and the development of a remote-controlled computer assisted suction device.

An air leak lasting longer than 5 to 7 days is considered a ‘prolonged or persistent air leak*’.

A prolonged air leak is one of the most frustrating complications after thoracic surgery for patients and clinicians alike.  Far from being life- threatening, a prolonged air leak often occurs in patients that are otherwise stable, healing well and potentially ready for discharge.  However, the presence of a persistent air leak can change all that – by limiting patient mobility and prolonging their hospital stay.

Surgeons have attempted to manage this problem in multiple ways in the past; including additional surgery, application of intra-operative glues and other sealants, repeated post-operative pleurodesis and the implantation of long-term devices like the Heimlich valve (to evacuate air while the lung heals).

More radical therapies such as radiation and endobronchial valves (EBV) have also been used with varying degrees of success (Erdoğan Çetinkaya, M. Akif Özgül, Şule Gül, Ertan Çam, Yakup Büyükpolat, 2012).

Ambulatory suction

In this study, Rocco designed a device capable of providing differing levels of suction independent of wall mounted suction**.  This in itself, is an important feat since being reliant on wall-mounted suction significantly limits the mobility and activity of otherwise ambulatory patients.

In standard cases, patients are essentially tethered to the suction mount in their rooms by a short length of suction tubing. This prolongs hospitalization and can contribute to the development of additional complications.

The Heimlich valve is often used in these cases to allow patients to be discharged home, despite a persistent air leak.  However, while the Heimlich valve relieves patients of this reliance on wall suction, this is also one of it’s limitations.  Independent of wall suction, the Heimlich valve prevents the entry of additional air into the pleural space but can not provide active suction to assist in lung healing.

Prior portable suction technologies

In my experience, our hospital had several antiquated portable suction units that allowed for limited ambulation.  These units were electric-powered suction units that could be wheeled alongside the patient (similar to wheeled oxygen units.)  But these units (dating from the 1950’s – 1960’s and which were found & rehabilitated from an old equipment room) still required the patient to remain in contact with a grounded electrical outlet, though the cord was lengthy.  They were used in limited circumstances in the intensive care and step-down units.

Portable suction unit used at Danville Regional Medical Center, Danville, Virginia.  Photo by Brian Compton
Portable suction unit used at Danville Regional Medical Center, Danville, Virginia. Photo by Brian Compton

Dr. Rocco’s device is a significant upgrade from the 1950’s version, and contains computer sensors to detect, and change the level of suction as needed.  It also contains a chargeable battery that allows patients to function independent of an electrical outlet for up to 48 hours.  This offers considerable freedom, and even permits home use in stable patients.

Continuous patient monitoring

With a laptop computer, both the surgeon and the patient can keep in contact, and monitor progress.  The surgeon can also adjust the amount of suction and review the continuously recorded air leak data.

In this case report, Rocco and his colleagues trialed the equipment  on a patient with a persistent air leak after a right upper lobectomy with wedge resection of the right lower lobe.  The patient was treated and monitored with this device during a stay in the step-down unit, the thoracic floor and finally, in an outpatient setting at a nearby guest house.

While this is a preliminary trial involving a single patient, the potential uses of these technology are considerable – given the frequency of prolonged air leaks post-operatively.  This is also important to consider as minimally invasive surgeries make it possible for patients to be medically stable and otherwise eligible for discharge earlier in the post-operative course.  Given the inherent risks (and costs) of prolonged hospitalization – this may become a viable option a part of a comprehensive discharge plan for many patients who would otherwise remain tethered to a suction mount in a hospital room.

Remote controlled suction -powerpoint slides from Annals of Thoracic Surgery article

* Seven days is the traditional time period but several authors have proposed this be shortened to five days.

** With assistance from Redax corporation.

Reference article

Rocco, G. (2013).  Remote-Controlled, Wireless Chest Drainage System: An Experimental Clinical Setting.  The Annals of Thoracic Surgery – January 2013 (Vol. 95, Issue 1, Pages 319-322, DOI: 10.1016/j.athoracsur.2012.09.079).   Requires subscription.

My apologies to readers – this article was actually published in January of this year, but was somehow overlooked until working on a separate study by Dr. Gaetano Rocco at the National Cancer Institute in Naples, Italy.

Additional References/ Reading

About/ Care of patients with Heimlich Valves – KPJ Ampang Puteri Specialty Hospital, Malaysia

Dimos Karangelis, Georgios I Tagarakis, Marios Daskalopoulos, Georgios Skoumis, Nicholaos Desimonas, Vasileios Saleptsis, Theocharis Koufakis, Athanasios Drakos, Dimitrios Papadopoulos, Nikolaos B Tsilimingas (2010).  Intrapleural instillation of autologous blood for persistent air leak in spontaneous pneumothorax- is it as effective as it is safe?  J Cardiothorac Surg. 2010; 5: 61. Published online 2010 August 17. doi: 10.1186/1749-8090-5-61.  The authors investigate the use of blood pleurodesis in fifteen patients and report a 27% success rate.

Erdoğan Çetinkaya, M. Akif Özgül, Şule Gül, Ertan Çam, Yakup Büyükpolat (2012).  Treatment of a Prolonged Air Leak with Radiotherapy: A Case Report.  Case Rep Pulmonol. 2012; 2012: 158371. Published online 2012 September 27. doi: 10.1155/2012/158371.  In this case report, surgeons in Istanbul, Turkey, radiation was applied to a localized area after the probably area of air leak was identified thru ventilation scintigraphy.  Patient received two doses of 10 G to a 10 X 10 cm area with resolution of air leak.

Cosimo Lequaglie, Gabriella Giudice, Rita Marasco, Aniello Della Morte, Massimiliano Gallo (2012).  Use of a sealant to prevent prolonged air leaks after lung resection: a prospective randomized study.  J Cardiothorac Surg. 2012; 7: 106. Published online 2012 October 8. doi: 10.1186/1749-8090-7-106.

Rathinam S, Steyn RS (2007). Management of complicated postoperative air-leak – a new indication for the Asherman chest seal. Interact Cardiovasc Thorac Surg. 2007 Dec;6(6):691-4. Epub 2007 Sep 11. Using a heimlich valve for persistent air leaks.

Tudor P Toma, Onn Min Kon, William Oldfield, Reina Sanefuji, Mark Griffiths, Frank Wells, Siva Sivasothy, Michael Dusmet, Duncan M Geddes, Michael I Polkey (2007).  Reduction of persistent air leak with endoscopic valve implants.  Thorax. 2007 September; 62(9): 830–833. doi: 10.1136/thx.2005.044537  Discussion of endobronchial valves (EBV).

mystery diagnosis: pleural plaques

Discovery of extensive pleural plaques during VATS

Usually with pleural plaques, you think of two possible diagnoses: metastatic cancer and tuberculosis.

But which is the more likely culprit?*  That kind of depends on both your patient and your geographic location.

If this had been in my native Virginia – I’d “assume/ guess” metastatic cancer  (since my patient population is usually older, high rate of smoking, other risk factors for cancer).

But luckily (who ever thought I’d be saying luckily) in my current location (Northern Mexico) in this patient (with multiple risk factors for infectious disease but no asbestos exposure) – tuberculosis is the more likely diagnosis.

* Prior to formal tissue pathology results, which confirmed tuberculosis in this patient.

** I apologize for the lack of formal references, but I was unable to find any comprehensive literature (available as free articles).

Radiology Reference on-line article

Pneumonectomy: for Tuberculosis

a discussion of Tuberculosis as a surgical disease, with a look at the historical perspectives.

Pneumonectomy, or surgical removal of one entire lung (versus removal of smaller segments of the lung) is a major surgery which is not performed without serious consideration to alternative treatments.  Pneumonectomy is indicated as the treatment of choice for otherwise unresectable cancers, as well as serious lung infections such as tuberculosis.

In fact, surgery for tuberculosis (including pneumonectomy) was one of the first set of procedures that helped establish thoracic surgery as a specialty.  In the era preceeding the development of antibiotics, there was no effective treatment for tuberculosis – which carried a high mortality rate.   Surgical resection of the affected lung was the treatment of choice.

Once antibiotics were established as an effective treatment for this disease, surgery faded into the background – and was primarily reserved for cases complicated by hemoptysis or empyema.

However, in recent years, due to the rise of multi-drug resistance tuberculosis (MDR-TB), surgical resection for the treatment of Tuberculosis has been making a comeback.  According to World Health Organization statistics; there were more than 8.8 million cases of TB in 2010.  While the death rate has fallen significantly (40%) since 1990 – over 1.4 million people died of TB during that same year.  In addition to multi-drug resistant Tuberculosis, there is another subtype called extensively drug resistant tubeculosis (XDR-TB) which is resistant to several drug regimens.  (Most cases of non-XDR forms of TB are currently treated with a four drug regimen for several months.)

The emergence of these antibiotic resistant strains have brought us full circle in the surgical management of the disease. Failure of medical therapies leads to a mortality of fifty percent (Kir, et. al (1997).  The re-emergence of surgery for tuberculosis is two-fold; surgery is used for both the treatment of active disease and the management of complications from tuberculosis (i.e. removal of dead or damaged lung tissue from previous TB infection.)

A review of the literature surrounding the surgical treatment of tuberculosis explores the modern surgical indications; potential complications and post-operative outcomes.   Shiraishi et al. (2008) detail their experiences with surgical resection of several cases of XDR-TB at a Tokyo facility.  As explained by Shiraishi, larger operations such as pneumonectomy are preferred over smaller resection procedures because the success of the operation hinges on the ability to remove all of the gross lesions (cavities) or destroyed tissue.

In this article (1997) from Saudi Arabia,  Ashour discusses his experiences (from 1985 to 1995) using pneumonectomy to treat post-TB lung destruction.

By reviewing several historical sources, we can review the changing perspectives regarding the treatment of tuberculosis and the indications for surgical resection.  While it may be surprising to many readers, the current indicators for surgical resection and pneumonectomy for tuberculosis encourage earlier surgical intervention.  In comparison to the late 20th century, where surgery was reserved for cases of extensive lung destruction with gross hemoptysis after years of unsuccessful medical treatment, the development of MDR- TB and XDR-TB provides for ample incentive for surgeons to intervene earlier in the disease process.

Additional References:

Imaging References: Post-pneumonectomy

This article by Padovani et al. (2009) demonstrates examples of normal chest radiographs following pneumonectomy. (article is in French).  Post-pneumonectomy films are shown sequentially, from immediately post-operatively, through recovery as the pneumonectomy space fills in.  (fig. 1 – 4a.) Figures 4b – 11 show different views of CT scans after pneumonectomy, including views showing partial pleurectomies with mesh placement.

Chandrashekhara SH, Bhalla AS, Sharma R, Gupta AK, Kumar A, Arora R. Imaging in postpneumonectomy complications: A pictorial review. J Can Res Ther 2011;7:3-10   More radiographs following pneumonectomy – depicting potential complications.  This is an excellent article reviewing potential early, late and chronic problems after pneumonectomy.

Tuberculosis:

 Scannel, J. G.  Tuberculosis as a surgical disease.

Naef, A. P. (1993).  The 1900 tuberculosis epidemic: starting point of thoracic surgery.

Sakula, A. (1983). Carlos Forlanini, inventor of artificial pneumothorax for treatment of pulmonary tuberculosisThorax 1983; 38: 326 – 332.

Shampo, M. A., & Rosenow III, E. C. (2009). A history of tuberculosis on stampsChest; 2009; 136; 578 – 582.

Telzak et. al (1995) explored the phenomenon of multidrug resistant TB in New York City from it’s emergence in the late 1980’s, early 1990’s in this paper, “Multidrug-resistant tuberculosis in patients without HIV infection.” published in the New England Journal of Medicine (1995; 333: 907- 911.)  In comparison to other studies, Telzak reported successful outcomes with medical management (at that point in time.)

CDC information on XDR-TB in the United States (1993 – 2006).

Surgical Management:

Adebonojo, S. A., Adebo, O. A., Osinowo, O., & Grillo, I. A. (1981). Management of tuberculosis destroyed lung in Nigeria.  Journal of the National Medical Association 1981; 73 (1): 39-42. Report of the results of 20 pneumonectomies performed (1969 – 1979) in cases of moderate to massive hemoptysis.  All of these patients were notably sicker than their western counterparts with active symptomology such as night sweats, weight loss, malnutrition, chest pain and varying degrees of hemoptysis.  75% had displayed symptoms for more than five years in spite of receiving several years of antibiotic therapies.  Despite this, surgical mortality was low, with acceptable surgical outcomes – giving an interesting historical perspective on this treatment.

Ashour, M. (1997). Pneumonectomy for tuberculosis.  Eur J Cardiothorac Surg 1997; 12: 209-213.  [full pdf cited in text above.]  This study is interesting since the average patient is several years younger than patients in the other studies presented here – demonstrating some of the geographic variability in disease patterns, which is discussed by the author of this article.

Harrison, E. (1967).  Present views on the application of surgery in the treatment of pulmonary tuberculosis. Dis Chest 1967; 52: 305 – 309.  A beautiful article reviewing the historical applications as well as current (1960’s) indications for surgical treatment of tuberculosis.

Kir, A., Tahaoglu, K., Okur, E., & Hatipoglu, T. (1997). Role of surgery in multi-drug-resistant tuberculosis: Results of 27 cases.  Eur J. Cardiothorac Surg 1997; 12: 531 – 534.  Turkish study.

Nuboer, J. F. (1956). Lung resection in the treatment of pulmonary tuberculosis.  Journal of National Medical Association 1956; 48 (6): 407 – 414.  Dutch paper on the use of surgical resection for the treatment of tuberculosis.

Pecora, D. (1965). Pneumonectomy for pulmonary tuberculosis. Dis Chest 1965; 48: 153 – 159.  Historical review of pneumonectomy for tuberculosis.

Quinlan, J. J., Schaffner, V. D., Kloss, G. A., & Hiltz, J. E. (1962). Pulmonary resection for tuberculosis: a review of 1257 operations.  Journal of the Canadian Medical Association, 1962; 86 (17).

Shiraishi, Y., Katsuragi, N., Kita, H., Toishi, M., & Onda, T. (2008). Experience with pulmonary resection for extensively drug resistance tuberculosis.  Interact CardioVasc Thorac Surg 2008; 7:1075-1078. [full text pdf link in text].

Shiraishi, Y., Katsuragi, N., Kita, H., Tominaga, Y., & Hiramalsu, M. (2010). Different morbidity after pneumonectomy: multidrug-resistant tuberculosis versus nontuberculosis mycobacterial infection.  Interact CardioVasc Thorac Surg 2010; 11:429-432.

Smith, R. A. (1982). The development of lung surgery in the United Kingdom.  Thorax 1982; 37: 161 -168. [full text cited above.].

Takahashi, N., Ohsawa, H., Mawatari, T., Watanabe, A. & Abe, T. Case Report: multidisciplinary treatment by pneumonectomy, PMX and CHDF in a case of pulmonary supparation complicated with septic shockAnn Thorac Cardiovasc Surg 2003; 9: 319-322.

Trapp, W. G., & Allan, M. L. (1963). Changing indications for resection of pulmonary tuberculosis.  Dis Chest 1963; 43: 486 – 493.

UCLA case studies in surgical management of TB and complications.

Yaldiz, S., Gursoy, S., Ucvet, A., & Kaya, S. (2011).  Surgery offers high cure rate for drug resistant tuberculosis.  Ann Thorac Cardiovasc Surg 2011; 17:143-147.  A Turkish study looking at pulmonary resection and chemotherapy for drug resistant TB in 13 patients (from Jan 2003 to Dec 2006).  High operative mortality (7.6%) in this study reflects small study size (1 patient).  No patients relapsed after surgery.

Robotic Thoracic Surgery

today, we are looking at the research and case reports related to the use of the Divinci robot for robot-assisted thoracic surgery..

I’m not sure if this should be filed under the Future of Thoracic Surgery – or news, since it won’t be long before more surgeons are performing their surgeries using the DiVinci robot.

I’ve already met a surgeon here in Bogota who has been training to start performing his lung surgeries using this technology.

It’s still a pretty new application of this robot – though reports go back to 2000, but it’s been slow to catch on in this specialty. The Divinci, which has been used for several years; in urology, gynecology and cardiac surgery is an expensive, large, unweldly machine so it takes consider time, and expense to get the necessary training and skills to use it appropriately.
However, one of the surgeons I know in Fresno, at the Stanford Cardiothoracic Surgery Clinic, Dr. Randy Bolton, has been using it for his cardiac cases for years..

So, today, we are looking at the research and case reports related to the use of the Divinci robot for robot-assisted thoracic surgery..

Robotic surgery for mediastinal tumors – Japan: a review of six cases including tomography, diagrams of staff positioning, and a discussion of port placement, as well as some of the problems they encountered (a lack of speciaized instruments).

The University of Illinois experience: 32 cases from 2001 – 2009 ; this study highlights some of the problems implementing new technologies – there is a significant learning curve, and it slows you down.. (The average operating time was 209 minutes). There are some color photos, so caution to the squeamish.

There are three articles pending publication on the use of robotic surgery for thoracic cases – one by Melfi, Vita, Divini and Mussi (European J Cardiothoracic Surgery)
and another, discussing 2 cases of pneumonectomy by robot by Spaggiari and Galetta that sound pretty intriguing.

I’ll see if I can update the article when the articles are more widely available.