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).

Rocco et al. “Ten year experience on 644 patients undergoing single-port (uniportal) video-assisted surgery

Reviewing “Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted” by Gaetano Rocco et al. at the National Cancer Institute in Naples, Italy

In this month’s issue of the Annals of Thoracic Surgery, Dr. Gaetano Rocco and his colleagues at the National Cancer Institute, Pascale Foundation in Naples, Italy reported their findings on ten year’s worth of single-port surgery in their institution.

Who:  644 patients; (334 males, 310 females)

Indications:

Annals of thoracic surgery - Rocco et. al (2013)
Annals of thoracic surgery – Rocco et. al (2013)

 

What:  Outcomes and experiences in single port thoracic surgery over a ten-year period.  All procedures performed by a single surgeon at this institution, and single-port VATS accounted for 27.7% of all surgeries performed during this time period.

When: data collected on thoracic surgery patients from January 2000 – December 2010.

Technical Notes:

Pre-operative CT scan was used for incision placement planning.  Incision was up to 2.5 cm (1 inch) in length depending on indications for surgery.

Since manual palpation of non-visible nodules is not possible using this technique, an ultrasound probe was used to identify these lesions.

Mean operating time was 18 minutes (diagnostic VATS) and 22 minutes for wedge resections.

Outcomes:

30 day Mortality: 0.6% (4 patients – all who presented with malignant effusions).

Major Morbidity: 2.8%

Persistent drainage requiring re-do talc pleurodesis: 13 patients

Prolonged airleak (more than 5 days): 13 patients

Atrial fibrillation: 4 patients

Pancreatitis: 1 patient

Conversion rate:  3.7% (overall)

Conversion rate to 2 or 3 port VATS: 2.2% (14 patients)

Conversion to mini-thoracotomy: 1.5% (10 patients)

Patients underwent conversion due to incomplete lung collapse (22 patients) and bleeding (2 patients).

There were no re-operations or “take backs”.  The four patients with malignant effusions who died within the 30 day post-op period were re-admitted to the ICU.

Post-operatively:

Otherwise, all patients were admitted to either the floor or the step-down unit following surgery.

Pain management: post-operative pain was managed with a non-narcotic regimen consisting of a 24 hour IV infusion pump of ketorolac (20mg) and tramadol (100mg*).  After the first 24 hours, patients were managed with oral analgesics such as paracetamol (acetaminophen).

Limitations:  in this study, uni-port VATS was not used for major resections, as seen in the work of Dr. Diego Gonzalez and others.  This may be due to the fact that uni-port VATS was an emerging technique at the initiation of this study.

Strengths:  This is one of the largest studies examining the use of single-port thoracic surgery – and showed low morbidity and mortality.  (Arguably, the 30 day mortality in this study was related to the patients’ underlying cancers, rather than the surgical procedure itself.)

*Intravenous tramadol is not available in the United States.

Reference article

Rocco, G., Martucci, N., La Manna, C., Jones, D. R., De Luca, G., La Rocca, A., Cuomo, A. & Accardo, R. (2013).  Ten years experience on 644 patients undergoing single-port (uniportal) video-assisted surgery.  Annals of Thoracic Surgery, 2013, Aug, 96(2): 434-438.

Additional work by these authors on uni-port VATS: (many of these articles require subscription).

Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg. 2004;77:726–728.

Rocco G. Single port video-assisted thoracic surgery (uniportal) in the routine general thoracic surgical practiceOp Tech (Society of Thoracic and Cardiovascular Surgeons). 2009;14:326–335.

Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseasesJ Thorac Cardiovasc Surg. 2005;129:947–948.

Rocco G, Brunelli A, Jutley R, et al. Uniportal VATS for mediastinal nodal diagnosis and stagingInteract Cardiovasc Thorac Surg. 2006;5:430–432

Rocco G, La Rocca A, La Manna C, et al. Uniportal video-assisted thoracoscopic surgery pericardial window. J Thorac Cardiovasc Surg. 2006;131:921–922.

Jutley RS, Khalil MW, Rocco G Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesiaEur J Cardiothorac Surg 2005;28:43-46.

Salati M, Brunelli A, Rocco G. Uniportal video-assisted thoracic surgery for diagnosis and treatment of intrathoracic conditions. Thorac Surg Clin. 2008;18:305–310.

Rocco G, Cicalese M, La Manna C, La Rocca A, Martucci N, Salvi R. Ultrasonographic identification of peripheral pulmonary nodules through uniportal video-assisted thoracic surgeryAnn Thorac Surg. 2011;92:1099–1101.

Rocco G, La Rocca A, Martucci N, Accardo R. Awake single-access (uniportal) video-assisted thoracoscopic surgery for spontaneous pneumothorax. J Thorac Cardiovasc Surg. 2011;142:944–945.

Rocco G, Romano V, Accardo R, et al. Awake single-access (uniportal) video-assisted thoracoscopic surgery for peripheral pulmonary nodules in a complete ambulatory setting. Ann Thorac Surg. 2010;89:1625–1627.

Recommended reading: Rocco G. (2012). One-port (uniportal) video assisted thoracic surgical resections – a clear advance. J Thorac Cardiovasc Surg.2012;144:S27–S31.

Additional articles on single-port surgery can be found in the new single-port surgery section, under “Surgical Procedures