Management of Air Leaks in Pulmonary Surgery

Air leaks represent one of the most common complications following pulmonary resection, extending hospital stay, increasing morbidity and driving healthcare costs. They occur when the visceral pleura fails to seal micro- or macro-disruptions in the lung parenchyma, leading to persistent communication between alveolar spaces and the pleural cavity. Management strategies range from refined surgical techniques—such as meticulous parenchymal suturing and staple-line reinforcement—to a spectrum of adjunctive measures including sealants, autologous tissue therapies, chest drainage systems and minimally invasive endobronchial devices. The overarching goal is rapid cessation of air leakage, optimisation of lung re-expansion and early removal of drainage, thereby reducing postoperative pain, preventing infection and shortening length of stay. Recent innovations have focused on biological sealants and tissue-engineering approaches to promote durable pleural closure, alongside digital monitoring of chest drains to guide evidence-based removal. Multidisciplinary decision-making now tailors interventions to leak severity, patient risk profile and anatomical considerations, underscoring a shift from one-size-fits-all protocols towards personalised management algorithms with demonstrable improvements in outcomes.

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Management of Air Leaks in Pulmonary Surgery publication trend

The graph below shows the total number of articles in management of air leaks in pulmonary surgery across all publications each year (not limited to Nature Index journals).

Technical terms

Prolonged air leak (PAL): An air leak persisting beyond postoperative day three, often delaying chest tube removal.

Bronchopleural fistula (BPF): A pathological connection between the bronchial tree and pleural space, typically following lobectomy or pneumonectomy.

Chest drain: A tube inserted through the chest wall to evacuate air and fluid from the pleural cavity, facilitating lung re-expansion.

Pleural sealant: A biological or synthetic material applied intraoperatively to reinforce tissue and seal air-leaking lung parenchyma.

Autologous mesenchymal stromal cells: Patient-derived bone marrow cells expanded ex vivo and used to promote tissue repair at surgical sites.

References

1. Autologous mesenchymal stromal cells embedded with Tissucol Duo® for prevention of air leak after anatomical lung resection: results of a prospective phase I/II clinical trial with long-term follow-up. Stem Cell Research & Therapy (2023).
2. Bronchopleural Fistula after Lobectomy for Lung Cancer: How to Manage This Life-Threatening Complication Using Both Old and Innovative Solutions. Cancers (2024).
3. A randomized controlled trial: Comparison of 14 and 24 French thoracic drainage after minimally invasive lobectomy – MZ 14-24 study. Heliyon (2023).
4. Bio-artificial pleura using an autologous dermal fibroblast sheet. npj Regenerative Medicine (2017).
5. Digital chest drainage system versus traditional chest drainage system after pulmonary resection: a systematic review and meta-analysis. Journal of Cardiothoracic Surgery (2019).
6. Endobronchial one-way valves for treatment of persistent air leaks: a systematic review. Respiratory Research (2017).