Alveolar-pleural fistulas causing persistent air leaks (PALs) are associated with prolonged hospital stays and high morbidity. Prior guidelines recommend surgical repair as the gold standard for treatment, albeit it is a solution with limited success. In patients who have recently undergone thoracic surgery or in whom surgery would be contraindicated based on the severity of illness, there has been a lack of treatment options. This review describes a brief history of treatment guidelines for PALs. In the past 20 years, newer and less invasive treatment options have been developed. Aside from supportive care, the literature includes anecdotal successful reports using fibrin sealants, ethanol injection, metal coils, and Watanabe spigots. More recently, larger studies have demonstrated success with chemical pleurodesis, autologous blood patch pleurodesis, and endobronchial valves. This manuscript describes these treatment options in detail, including postprocedural adverse events. Further research, including randomized controlled trials with comparison of these options, are needed, as is long-term follow-up for these interventions.

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Objective To determine if SNPs in TLR1 are associated with mortality, specifically sepsis-associated mortality, in a traumatically injured population. Summary Background Data Innate immune responses mediated by toll-like receptors (TLRs), induce early inflammatory responses to pathogen and damage-associated molecular patterns. Genetic variation in TLRs has been associated with susceptibility and outcomes in a number of infectious and non-infectious disease states. Methods Patients admitted to the trauma intensive care unit at a level one trauma center serving 4 states were enrolled and followed for development of infection, sepsis, and death. Genomic DNA was genotyped and logistic regression analysis performed to determine associations between TLR1 SNPs and mortality. We further examined for associations between TLR1 SNPs and mortality in subgroups based on the presence of sepsis and the type of sepsis-associated organism. Results We enrolled 1,961 patients.TLR1-7202G (rs5743551) was associated with increased mortality after traumatic injury and this association was primarily observed in the subset of patients who developed sepsis (adjusted OR 3.16; 95% CI 1.43–6.97, P=0.004). This association persisted after further restriction to gram-positive sepsis. TLR1742A/G(Asn248Ser) (rs4833095), a coding SNP in LD with TLR1-7202Gwas also associated with mortality in gram-positive sepsis (adjusted OR 4.16; 95% CI 1.22–14.19, P=0.023). Conclusion Genetic variation in TLR1 is associated with increased mortality in patients with sepsis following traumatic injury and may represent a novel marker of risk for death in critically injured patients.

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