A Delphi Consensus report from the "Prolonged Air Leak: A Survey" study group on prevention and management of postoperative air leaks after minimally invasive anatomical resections

Abstract

OBJECTIVES This study reports the results of an international expert consensus process evaluating the assessment of intraoperative air leaks (IAL) and treatment of postoperative prolonged air leaks (PAL) utilizing a Delphi process, with the aim of helping standardization and improving practice. METHODS A panel of 45 questions was developed and submitted to an international working group of experts in minimally invasive lung cancer surgery. Modified Delphi methodology was used to review responses, including 3 rounds of voting. The consensus was defined a priori as >50% agreement among the experts. Clinical practice standards were graded as recommended or highly recommended if 50–74% or >75% of the experts reached an agreement, respectively. RESULTS A total of 32 experts from 18 countries completed the questionnaires in all 3 rounds. Respondents agreed that PAL are defined as >5 days and that current risk models are rarely used. The consensus was reached in 33/45 issues (73.3%). IAL were classified as mild (<100 ml/min; 81%), moderate (100–400 ml/min; 71%) and severe (>400 ml/min; 74%). If mild IAL are detected, 68% do not treat; if moderate, consensus was not; if severe, 90% favoured treatment. CONCLUSIONS This expert consensus working group reached an agreement on the majority of issues regarding the detection and management of IAL and PAL. In the absence of prospective, randomized evidence supporting most of these clinical decisions, this document may serve as a guideline to reduce practice variation.

Evaluating and developing sealants for the prevention of pulmonary air leakage: A systematic review of animal models

“…Recent consensus guidelines advice to classify air leaks as mild (<100 ml/min), moderate (100–400 ml/min) and severe (>400 ml/min). 54 In other studies, intraoperative PAL >500 ml/min or >9.5% of the inspiratory tidal volume have been found to be predictive of pPAL. 55,56 Similar classification might also apply to larger animals such as sheep and pigs.…”

A brief appraisal on the GRADE methodology and the development of recommendations on the management of prolonged air leaks by the PALAS Study Group

“…Grading of Recommendations, Assessment, Development and Evaluation (GRADE) is a tool that systematic reviewers and guideline developers use to evaluate the quality of evidence and determine whether to propose an intervention (1). GRADE is distinct from previous appraisal tools.…”

“…The lack of evidence-based guidelines on PAL burdens the routine activity of the thoracic surgeon, especially in the younger generation. Recently, the PALAS Study Group, through an international 3-round Delphi survey, reached an agreement on some relevant issues concerning the detection and management of intraoperative alveolar air leak and PAL but failed on others (1).…”

Development of a multivariable prediction model for prolonged air leak after lung resection

“…Operative closure remains a radical treatment for PAL. 9 Furthermore, it enables the use of patient-specific appropriate postoperative antibacterial therapy and pyothorax prophylaxis in patients with a high PAL risk score. We consider that both treatment strategies have the potential to be effective and that aggressive treatment strategies should not be ruled out in cases with a high-risk of PAL.…”

“…Some studies have shown that DDS measurements of postoperative air leak flow 8 and air leak patterns can predict PAL 2 . In practice, at many institutions, there is already an expert consensus that the air leak volume is a useful predictor of subsequent PAL 9 . Few prediction models have focused on the intrapleural pressure and its fluctuations 10,11 .…”