Management of alveolopleural fistula

* Most patients respond to conservative therapy (up to 80% in our experience). It is controversial whether or not low wall suction should be applied. However, our preference for suction is based upon the likelihood of increased adherence of the visceral and parietal membranes, thereby promoting healing and closure of the fistula. Suction should not be applied in those with unexpandable lung. Some patients with large leak need a second chest tube and high suction. There is no optimal follow-up time for patients who undergo conservative therapy. Nonetheless, in general, smaller air leaks that are improving with time (eg, one to two weeks) are more likely to spontaneously undergo closure with conservative management than larger air leaks that have been present for a prolonged period of time and are not improving despite conservative therapy; the latter are unlikely to resolve spontaneously and require intervention.
¶ Refer to UpToDate text for details of this evaluation.
Δ Several options are available, none of which are proven to be superior over the other. However, our preference is for endobronchial valve placement. Other options include silicone plugs or sealants such as fibrin glue and rarely stent placement.
◊ Ambulatory drainage devices include pneumostat, Heimlich valve, chest drain valve, mobile dry seal, and digital chest tube drainage. Chest drain valves, Heimlich valves, and mobile dry seal drains can only be placed once the patient demonstrates no pneumothorax on water seal while digital chest tube drains can be placed even when the patient requires continuous suction. Patients can be discharged home with these devices as long as they are asymptomatic without subcutaneous emphysema or enlarging pneumothorax size. Pleural interventions include non-surgical chemical pleurodesis and autologous blood patch (refer to UpToDate text for details).