Management of persistent air leaks

Key points

• A persistent air leak (PAL) is usually defined as an air leak continuing beyond 5-7 days after intrapleural catheter placement; it is associated with prolonged hospitalisation, morbidity, mortality and cost.
• The ACCP consensus advises observing a bronchopleural fistula for spontaneous closure for four days and then evaluating surgical closure and pleurodesis, with thoracoscopy preferred; the 2023 BTS guidelines recommend considering autologous blood pleurodesis and endobronchial therapies in patients who are not surgical candidates.
• Autologous blood patch pleurodesis (typically 60-120 mL or 2 mL per kg of the patient's blood) stopped the leak in 85% of patients in the first series and in 92-93% in later studies.
• Endobronchial valves have the most published experience among bronchoscopic options; in two reviews the leak resolved within 24 hours in 67% and 62% of patients.
• The authors advise conservative management for the first 5-7 days unless the leak causes haemodynamic or respiratory instability, and then surgical or bronchoscopic intervention if there is no trend toward improvement.

Overview

This 2026 opinion article reviews newer and less invasive treatments for persistent air leaks caused by alveolar-pleural or broncho-pleural fistulas. PAL may follow primary or secondary pneumothorax, infection, mechanical ventilation or thoracic surgery; its incidence after lung volume reduction surgery is 8-45%. Risk factors after lobectomy include COPD, female sex, lower FEV1, smoking, diabetes and chronic steroid use. Severity is often graded with the Cerfolio system, from grade 1 (leak only on forced expiration) to grade 4 (continuous leak).

Guideline positions

The ACCP consensus does not recommend a second chest tube, advises chemical pleurodesis only when surgery is contraindicated or refused, with doxycycline or talc slurry preferred, and recommends against bronchoscopic management. The 2023 BTS guideline notes that no single intervention is universally preferred because high-quality evidence is limited, and that autologous blood pleurodesis reduces length of stay compared with chest drainage alone.

Endobronchial options

Bronchoscopic options include sealants such as fibrin glue or hydrogel, silicone spigots, metal coils, covered stents and endobronchial valves. In the United States only the Spiration valve has Humanitarian Device Exemption approval for PAL (granted October 2008). The culprit airway is identified by sequential balloon occlusion or Chartis assessment before valve placement. Limitations include collateral ventilation, granulation tissue, pneumonia, valve migration and central defects of 8 mm or more, and no randomised controlled trial has been completed. The authors recommend removing valves after about 6 weeks, reinserting them for another 6 weeks if pneumothorax recurs, and surgery if it recurs again.

FAQ

When is an air leak considered persistent?

Typically when it continues beyond 5-7 days after intrapleural catheter placement.

What is an autologous blood patch?

Instillation of the patient's own blood, usually 60-120 mL or 2 mL per kg, through the chest tube to seal the leak and promote pleurodesis, without the need for anaesthesia.

How long do endobronchial valves stay in?

The authors recommend removal after about 6 weeks, when the pleural defect should have healed.

Source

Serna S, Khan M, Shingada K, et al. Management of Persistent Air Leak. J Respir 2026;6(2):8. DOI: 10.3390/jor6020008. Open access under CC BY 4.0. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.