Evaluation and endoscopic management of persistent air leaks

The endoscopic management of persistent or prolonged air leak (PAL) has gained popularity, not only in post-surgical PAL but also in non-surgical scenarios. The literature that supports an endoscopic approach is restricted to case series, case reports, retrospective and some small prospective studies. Every patient who suffers from PAL secondary to bronchopleural fistula (BPF) or alveolopleural fistula (APF) should always be evaluated to determine surgical repair candidacy. There have been a number of articles that summarize the bronchoscopic modalities for the management of PAL, but none emphasize the initial evaluation with an algorithmic approach or discuss how to follow-up these patients in the immediate post- treatment phase and long-term. Medical causes of PAL are, in our opinion, more difficult to localize and consequently treat compared to surgical causes of air leak. The bronchoscopic management for either surgical or non-surgical BPF’s is similar. In this review, we discuss the initial evaluation, management and follow up with an algorithmic approach of PAL as well as review the available endoscopic modalities.