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• W2736725688 abstract "We read with great interest the study by Gilbert and colleagues [1Gilbert S. Maghera S. Seely A.J. et al.Identifying patients at higher risk of prolonged air leak after lung resection.Ann Thorac Surg. 2016; 102: 1674-1679Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar] on identifying patients at higher risk of prolonged air leak after lung resection (PAAL). Male sex, smoking history, body mass index less than or equal to 25 kg/m2, Medical Research Council dyspnea score greater than 1, and diffusing capacity of the lungs for carbon monoxide (Dlco) less than 80% showed an association with the occurrence of PAAL. All these factors, especially a low Dlco, are associated with the emphysema-phenotype of chronic obstructive pulmonary disease. Interestingly, in previous studies computed tomography (CT) quantification of emphysema was found to be one of the best predictors of PAAL [2Petrella F. Rizzo S. Radice D. et al.Predicting prolonged air leak after standard pulmonary lobectomy: computed tomography assessment and risk factors stratification.Surgeon. 2011 Apr; 9: 72-77Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 3Liang S. Ivanovic J. Gilbert S. et al.Quantifying the incidence and impact of postoperative prolonged alveolar air leak after pulmonary resection.J Thorac Cardiovasc Surg. 2013 Apr; 145: 948-954Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar]. With this letter, we want to expand on the discussion on a possible physiologic basis of the association between emphysema and the risk for PAAL. In emphysema, airway resistance can exceed collateral airflow resistance, causing air to flow preferentially through collateral pathways [4Chahla M. Larson C.D. Parekh K.R. et al.Transpleural Ventilation via Spiracles in Severe Emphysema Increases Alveolar Ventilation.Chest. 2016; 149: e161-e167Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Khauli S. Bolukbas S. Reed R.M. Eberlein M. Interlobar collateral ventilation in severe emphysema.Thorax. 2016; PubMed Google Scholar]. Collateral ventilation can connect airspaces of an entire lung when incomplete fissures are present [5Khauli S. Bolukbas S. Reed R.M. Eberlein M. Interlobar collateral ventilation in severe emphysema.Thorax. 2016; PubMed Google Scholar]. Thus, in the setting of pleuro-parenchymal tears of an emphysematous lung, transpleural airflow out through the tear can be a pathway of lower resistance (mediated with collateral ventilation) than expiratory airflow through the (chronically obstructed) airways [4Chahla M. Larson C.D. Parekh K.R. et al.Transpleural Ventilation via Spiracles in Severe Emphysema Increases Alveolar Ventilation.Chest. 2016; 149: e161-e167Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Khauli S. Bolukbas S. Reed R.M. Eberlein M. Interlobar collateral ventilation in severe emphysema.Thorax. 2016; PubMed Google Scholar]. We previously described complete transpleural exhalation in patients with severe emphysema, when the pleura or parenchyma is punctured inadvertently during dissection of the lung from the chest wall [4Chahla M. Larson C.D. Parekh K.R. et al.Transpleural Ventilation via Spiracles in Severe Emphysema Increases Alveolar Ventilation.Chest. 2016; 149: e161-e167Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Khauli S. Bolukbas S. Reed R.M. Eberlein M. Interlobar collateral ventilation in severe emphysema.Thorax. 2016; PubMed Google Scholar]. In addition to emphysema as an established independent risk factor for PAAL, these physiologic considerations could suggest that incomplete fissures are additional or synergistic risk factors for PAAL. Future studies using quantitative analysis of CT scans to determine emphysema severity and distribution and fissure integrity could provide important novel information to allow enhanced risk stratification to identify patients at risk for PAAL. Identifying Patients at Higher Risk of Prolonged Air Leak After Lung ResectionThe Annals of Thoracic SurgeryVol. 102Issue 5PreviewPredictive models of prolonged air leak have relied on information not always available preoperatively (eg, extent of resection, pleural adhesions). Our objective was to construct a model to identify patients at increased risk of prolonged air leak using preoperative factors exclusively. Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 104Issue 2PreviewFirst, we would like to thank Dr Eberlein and colleagues [1] for enriching our contribution [2] with thoughtful, evidence-based comments focusing on other potential strategies to identify patients who may be at increased risk for a prolonged air leak after lung resection. Despite meticulous care and attention to detail in the handling of tissues during surgery, it seems unlikely that the incidence of prolonged air leaks will be further minimized unless we develop new ways to mitigate this problem effectively. Full-Text PDF" @default.
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• W2736725688 title "Prolonged Air Leak After Lung Resection and Emphysema" @default.
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