Challenges in the treatment of persistent air leak

Prolonged air leak (PAL) is associated with prolonged hospital stay with high healthcare costs and increased mortality. PAL can develop due to fistula at the alveolar level [alveolar-pleural fistula (APF)] or at the bronchial level [bronchopleural fistula (BPF)]. In patients who fail conservative management with chest tube drainage alone, there are both surgical and non-surgical options that have been studied or reported to reduce or stop the air leak. PAL continues to be a challenging problem and requires a multidisciplinary management approach among interventional pulmonologists, interventional radiologists and thoracic surgeons. While surgical consultation and options are considered as the gold standard for treatment in the previously published guidelines, some of the newer bronchoscopic treatment modalities have shown success treating complicated patients with PAL. Non-surgical management includes use of autologous blood patch (ABP), chemical pleurodesis, insertion of one-way bronchial valves, and use of sealants and implants. In recent years, bronchoscopic approach gained popularity because of their less invasive nature and reversibility in some instances in both post-surgical and non-surgical reasons of PAL. Reported success rates and complications are included in this review. Further areas of research should include conducting randomized controlled trials between different methods and assessment of any long-term complications from these interventions. We aim to cover the existing methods of diagnosis, treatment and provide challenges, biases and limitations of the current literature in patients with PAL.