title: A clinical prediction model for prolonged air leak after pulmonary resection.
abstract: Prolonged air leak increases costs and worsens outcomes after pulmonary resection. We aimed to develop a clinical prediction tool for prolonged air leak using pretreatment and intraoperative variables.
  
  
  
  Patients who underwent pulmonary resection for lung cancer/nodules (from January 2009 to June 2014) were stratified by prolonged parenchymal air leak (>5 days). Using backward stepwise logistic regression with bootstrap resampling for internal validation, candidate variables were identified and a nomogram risk calculator was developed.
  
  
  
  A total of 2317 patients underwent pulmonary resection for lung cancer/nodules. Prolonged air leak (8.6%, n = 200) was associated with significantly longer hospital stay (median 10 vs 4 days; P < .001). Final model variables associated with increased risk included low percent forced expiratory volume in 1 second, smoking history, bilobectomy, higher annual surgeon caseload, previous chest surgery, Zubrod score >2, and interaction terms for right-sided thoracotomy and wedge resection by thoracotomy. Wedge resection, higher body mass index, and unmeasured percent forced expiratory volume in 1 second were protective. Derived nomogram discriminatory accuracy was 76% (95% confidence interval [CI], 0.72-0.79) and facilitated patient stratification into low-, intermediate- and high-risk groups with monotonic increase in observed prolonged air leaks (2.0%, 8.9%, and 19.2%, respectively; P < .001). Patients at intermediate and high risk were 4.80 times (95% CI, 2.86-8.07) and 11.86 times (95% CI, 7.21-19.52) more likely to have prolonged air leak compared with patients at low risk.
  
  
  
  Using readily available candidate variables, our nomogram predicts increasing risk of prolonged air leak with good discriminatory ability. Risk stratification can support surgical decision making, and help initiate proactive, patient-specific surgical management.
authors.affiliation: Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: Adam
authors.initials: A
authors.lastname: Attaar
authors.affiliation: Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Winger
authors.affiliation: Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: James D
authors.initials: JD
authors.lastname: Luketich
authors.affiliation: Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Schuchert
authors.affiliation: Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: Inderpal S
authors.initials: IS
authors.lastname: Sarkaria
authors.affiliation: Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
authors.forename: Neil A
authors.initials: NA
authors.lastname: Christie
authors.affiliation: Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa. Electronic address: nasonks@upmc.edu.
authors.forename: Katie S
authors.initials: KS
authors.lastname: Nason
mesh_terms: D000368:Aged; D057868:Anastomotic Leak / Q000453:epidemiology*; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D015994:Incidence; D008175:Lung Neoplasms / Q000601:surgery*; D008297:Male; D010414:Pennsylvania / Q000453:epidemiology; D011013:Pneumonectomy / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D020775:Thoracic Surgery, Video-Assisted / Q000009:adverse effects; D013997:Time Factors
keywords: air leak; funnel plot; lung cancer; multivariable; persistent air leak; prolonged air leak; pulmonary resection; risk factors; risk stratification