title: Recent advances in the treatment of air leaks.
abstract: OBJECTIVE
  Alveolar-pleural fistulas (air leaks) are an extremely common clinical problem and remain the most common complication after elective pulmonary resection and video-assisted procedures. The decision making process used to manage air leaks and chest tubes that control them has been, until very recently, based on opinions and training preferences as opposed to facts derived from randomized clinical trials.
  
  
  RESULTS
  Recently, several prospective randomized trials have studied air leaks. An objective, reproducible classification system has also been designed and clinically validated to help study air leaks. This system and these studies have shown that water seal is superior to wall suction to help stop most leaks. Even in patients with a pneumothorax and an air leak, water seal is safe and best; however, if a patient has a large leak (greater than an expiratory 3 on the classification system) or experiences subcutaneous emphysema or an expanding pneumothorax that causes hypoxia, then some suction (-10 cm of water) should be applied to the chest tubes.
  
  
  CONCLUSIONS
  Air leaks were a poorly understood yet extremely common clinical problem that had never been scientifically studied. Over the past 5 years, prospective randomized studies have shown that water seal is the best setting for chest tubes and that a pneumothorax is not a contraindication to leaving tubes on seal. Further studies are needed to investigate the ideal management of alveolar-pleural fistulas (air leaks) in different clinical scenarios besides those that occur postoperatively.
authors.affiliation: Section of Thoracic Surgery, University of Alabama at Birmingham, 35294, USA. Robert.cerfolio@cc.uab.edu
authors.forename: Robert James
authors.initials: RJ
authors.lastname: Cerfolio
mesh_terms: D015505:Chest Tubes; D006801:Humans; D010995:Pleural Diseases / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D011650:Pulmonary Alveoli; D016156:Respiratory Tract Fistula / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D012307:Risk Factors; D013907:Thoracostomy