Diluted Fibrin Glue for Intractable Pneumothorax
Diluted Fibrin Glue for Intractable Pneumothorax
Abstract & Commentary
Synopsis: Fluoroscopically-guided intrapleural administration of fibrin glue is effective in treating persistent pneumothorax.
Source: Kinoshita T, et al. Intrapleural administration of a large amount of diluted fibrin glue for intractable pneumothorax. Chest 2000;117:790-795.
Persistent pneumothorax despite chest tube drainage remains a common problem in hospitalized patients, particularly those with chronic obstructive lung disease (COPD) and patients who have undergone thoracotomy for resection of bullae, blebs, or malignant tumors. While intrapleural administration of chemical sclerosing agents is often effective in patients with air leaks whose lungs reexpand following tube drainage, the efficacy of these agents that include doxycycline, bleomycin, and talc is often limited when apposition of the pleural surfaces cannot be achieved because of persistent pneumothorax.
In this study, two groups of patients were treated: 40 high-risk patients with intractable pneumothorax (most with COPD or blebs [Group A]), and 13 postthoracotomy patients (most postlobectomy for cancer) with persistent postoperative air leaks (Group B). Kinoshita and colleagues developed a four-fold dilute solution of fibrin glue by adding both saline and contrast to each of the two components of fibrin glue (fibrinogen and thrombin). The addition of the iopamidol 300 mg% (Iopamiron 300, Schering, Berlin, Gremany) allowed visualization of the distribution of the fibrin glue over the surface of the lung. Under fluoroscopic guidance, the fibrin glue was administered to the site of bubbling from the lung surface by infusing the solution through one of two ports of a double lumen chest tube and then rotating the patient to improve distribution of the glue over the entire surface of the lung. After each of the two component solutions of fibrin glue were administered, the chest tube was clamped for five minutes and then attached to low level suction at -8 cm H2O. In the absence of lung collapse or air leak, the tube was removed three days after the fibrin glue administration.
Of the 40 Group A patients, 87.5% had successful cessation of their air leak. This included five patients on mechanical ventilation in whom all were subsequently weaned from the ventilator. All Group B patients were successfully treated. Side effects from the procedure included fever in 12.5% and discomfort in 4%.
Comment by Jeffrey S. Klein, MD
The management of hospitalized patients with persistent pneumothorax remains a significant clinical problem, particularly elderly patients with significant comorbid disease that renders them poor candidates for operative management of pneumothorax via thoracoscopy or thoracotomy. Prior attempts at developing bronchoscopic techniques of managing prolonged air leak and bronchopleural fistula formation have been variably successful and, therefore, have not gained widespread acceptance. The technique described in this study would appear to offer an alternative method of treating these high-risk patients by using fluoroscopically-administered contrast-enhanced fibrin glue to seal air leaks in these patients, and in some cases aid in weaning from mechanical ventilation. It is somewhat unclear from the materials and methods section of this study exactly how difficult it is to localize the site of air leak and effectively target this area with the fibrin glue solution. However, the increasing availability and use of CT-fluoroscopy for real-time visualization of the thorax might provide an effective means of targeting the appropriate site of glue deposition for maximum effectiveness.
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