Persistent Air Leak Management in Critically Ill Patients

Persistent air leak (PAL) is a challenging clinical entity, particularly in the setting of critical illness. It is a significant cause of morbidity, health care expenditure, and resource utilization. Data on its prevalence in the critically ill patient population are limited. Unique patient factors often necessitate an individualized approach. Guidelines on this subject are antiquated and do not specially address patients on mechanical ventilation. Critically ill patients may not be able to tolerate surgical intervention. Treatment in this population relies upon lung protective ventilation, various anecdotal modalities, chemical pleurodesis, autologous blood patching, and bronchoscopic insertion of endobronchial valves. Ventilation strategies center on rapid weaning and reduction of airway pressures. Anecdotal methods include implantable devices and chemical agents. Data on these modalities are limited to case reports. None have United States Food and Drug Administration (FDA) approval. The Spiration Valve System is FDA approved as a Humanitarian Device Exemption. Data on endobronchial valves are based on large case series, and only one small case series has focused exclusively on critically ill patients. The majority of valves in critically ill mechanically ventilated patients are used for non-FDA approved indications. Updated guidelines are desperately needed to ensure a standardized approach to this common clinical situation.