Endobronchial valve placement for spontaneous pneumothorax from stage IIIA non-small cell lung cancer facilitates neoadjuvant therapy

Spontaneous pneumothorax has previously been described as a presenting symptom of lung cancer. This presentation can, unfortunately, complicate and delay further definitive oncologic care until the pneumothorax can be effectively managed. We describe the case of a 58-year-old man who presented with secondary spontaneous pneumothorax and persistent air leak related to his primary lung carcinoma. Endobronchial valve placement allowed for the avoidance of pleurodesis, timely discharge, and neoadjuvant chemotherapy, followed by definitive surgical resection.

Advances in interventional pulmonology

Interventional pulmonology (IP) remains a rapidly expanding and evolving subspecialty focused on the diagnosis and treatment of complex diseases of the thorax. As the field continues to push the leading edge of medical technology, new procedures allow for novel minimally invasive approaches to old diseases including asthma, chronic obstructive pulmonary disease and metastatic or primary lung malignancy. In addition to technologic advances, IP has matured into a defined subspecialty, requiring formal training necessary to perform the advanced procedures. This need for advanced training has led to the need for standardization of training and the institution of a subspecialty board examination. In this review, we will discuss the dynamic field of IP as well as novel technologies being investigated or employed in the treatment of thoracic disease.

Endobronchial valve placement and balloon occlusion for persistent air leak: procedure overview and new current procedural terminology codes for 2013

Unidirectional endobronchial valves, originally studied for potential treatment of emphysema, have emerged as a useful intervention for patients with persistent air leak from the lung. The procedure is accomplished via bronchoscopy in a patient who already has a chest tube in place for management of the air leak. It uses an occluding balloon to determine the specific airway(s) leading to the leak by impact on airflow and subsequent placement of removable valve(s) in one or more segment or subsegments to decrease flow across the leak to allow for healing of the fistula. Specific US Food and Drug Administration-approved criteria for placement and removal of these valves via a Humanitarian Device Exemption are discussed along with reported outcomes. Current Procedural Terminology codes effective for 2013 that are specific to the procedure are reviewed.

Clinical challenges of persistent pulmonary air-leaks--case report

Air leaks are a common problem after pulmonary resection and can be a source of significant morbidity and mortality. The authors describe the case of a 68-year-old male patient who presented with a persistent air-leak after pulmonary resection. Watchful waiting, surgical procedures, as well as medical therapy like pleurodesis and implantation of endobronchial one-way valves on the bronchial segments identified using systematic occlusion of the bronchial segments, were all tried unsuccessfully. During that time the patient remained hospitalized with a chest tube. The instillation of methylene blue through the chest tube was used to identify the segments leading to the persistent air-leak; this enabled successful endobronchial valve placement which sufficiently reduced the size of the air-leak so that the chest tube could be removed. Nonsurgical approaches seem promising and, for some patients may be the only treatment option after all conventional treatments have failed or are considered too high risk.

Endobronchial valves for treatment of bronchopleural fistula in granulomatous polyangitis: a longitudinal case report

Bronchopleural fistula (BPF) is an abnormal communication between the bronchus and the pleural space, commonly occurring after pulmonary resection or due to a spontaneous pneumothorax secondary to an underlying lung disease. We present a case of BPF in the setting of granulomatous polyangitis treated with endobronchial valves (EBV) with a longitudinal follow-up. These 1-way valves allow air and mucus to exit the diseased segment of lung during expiration, but prevent the reentry of air upon inspiration. The targeted segment may undergo atelectasis, achieving nonsurgical lung volume reduction, and allowing the remaining lung to compensate for the loss of volume. The use of these valves has shown to decrease hospitalization, morbidity, and mortality in these patients. In this case, the patient endured a prolonged hospitalization (82 d) and was able to be discharged only 7 days after EBV placement. This facilitated engagement in a pulmonary rehabilitation program, increased physical activity, and ultimately resumption of normal activity for the patient. To our knowledge, this is the first case of EBV used to treat BPF in the setting of underlying granulomatous polyangitis. This underscores the point that in appropriate settings, EBVs can decrease morbidity and mortality, and significantly improve the quality of life.

Successful closure of bronchopleural fistula with Xeroform dressing

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree, and is associated with significant morbidity and mortality. Treatment options for BPF include surgical closure and medical therapy. In an unstable patient, invasive surgical intervention is not an option. In this article, we report the case of a 61-year-old man who developed pneumothorax with a large BPF after a bronchoscopic resection of a malignant endobronchial lesion. We inserted a piece of 1.5×1.5-cm Xeroform dressing to seal the massive air leak with successful closure of the BPF. To our knowledge, this is the first report of successful closure of a massive BPF with Xeroform dressing in an acutely decompensating patient.

Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients

BACKGROUND

Bronchopleural fistulas (BPF) are conditions associated with prolonged hospital course, high morbidity, and possibly increased mortality. The presence of BPFs in critically ill patients may cause difficulty in ventilation and increased oxygen requirements. Intrabronchial valves (Spiration IBV) serve as a noninvasive therapeutic option for the closure of BPFs.

METHODS

This report is a retrospective description of 3 patients transferred to our medical intensive care unit (ICU) with BPFs and persistent air leaks (PAL). One patient required high levels of oxygen supplementation through a nonrebreather face mask, whereas 2 required mechanical ventilation because of respiratory failure. IBVs were placed in each patient with the intention of closing their BPF and weaning them from respiratory support.

RESULTS

The use of IBVs in ICU patients with BPFs and PALs resulted in 1 patient being weaned from the persistent need for a nonrebreather face mask to room air and also aided in the liberation from mechanical ventilation of 2 patients who had been failing spontaneous breathing trials.

CONCLUSIONS

The use of IBVs is safe and well tolerated in ICU patients with BPFs and PALs. The placement of IBVs results in significant clinical improvement, allowing for either weaning from high levels of oxygen support or liberation from mechanical ventilation.

Treatment of intractable pneumothorax with emphysema using endobronchial watanabe spigots

Prolonged air leakage is a major cause of morbidity in pneumothorax. When conservative management is not effective, surgery should be performed. However, surgery is not appropriate in patients with low pulmonary function. In these patients, occlusion of the airway with endobronchial blockers may be attempted under bronchoscopy. We treated two patients with prolonged air leakage using endobronchial Watanabe spigots under fibrobronchoscopy.

Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring

BACKGROUND

Prolonged alveolar-pleural air leaks are associated with increased morbidity and mortality. Endoscopic valve therapy has been recently introduced as a potential less invasive treatment option. We aimed at quantifying the effects of valve therapy on air leak flow and clinical outcomes in patients with prolonged air leaks.

METHODS

We report on a series of 16 patients with high comorbidity and evidence of continuous air leak flow in whom chest tubes remained in place for at least 7 days. After identification of the source of the air leak by use of the balloon occlusion technique, endobronchial one-way valves were implanted. Digital chest tube monitoring was used to assess air leak flow before, during, and after valve implantation until chest tube removal.

RESULTS

The source of the air leak was endoscopically identified in 13 patients (81%). After valve implantation, air leak flow decreased significantly from 871±551 mL/min to 61±72 mL/min immediately after the intervention (p<0.001). The mean duration of chest tube drainage was 18±8 days before and 9±6 days after the intervention (p<0.01). Ten patients were considered responders, and 3 patients were nonresponders. Responders demonstrated consistent air leak flow levels below 100 mL/min until chest tube removal. Long-term follow-up was available for 9 patients. No adverse events related to the valve implants were reported at follow-up. Seven patients underwent valve removal without any further complications.

CONCLUSIONS

Endoscopic implantation of one-way valves leads to a significant reduction in air leakage flow and may thus be a valuable treatment option in patients with prolonged air leakage.

Isolation of persistent air leaks and placement of intrabronchial valves

OBJECTIVES

Alveolar-pleural fistulas causing persistent air leaks are conditions associated with prolonged hospital courses, high morbidity, and possibly increased mortality. Intrabronchial valves serve as a noninvasive therapeutic option for the closure of alveolar-pleural fistulas.

METHODS

The present review describes a brief history of, and indications for, the placement of intrabronchial valves in patients with persistent air leaks. The essential steps necessary for placement are air leak isolation, airway sizing, and valve deployment. Additionally, the indications and methods for intrabronchial valve removal, along with the potential complications from intrabronchial valve placement, are described.

CONCLUSIONS

The increased use of intrabronchial valves in the treatment of persistent air leaks requires bronchoscopists and clinicians to understand the procedural steps and techniques necessary for intrabronchial valve placement.

Treatment of a prolonged air leak with radiotherapy: a case report

Pneumothorax is defined as air in the pleural space. Depending on the severity of the pneumothorax, treatment consists of oxygen therapy, simple aspiration, tube thoracostomy, and pleurodesis. Prolonged air leakage is observed in 25% of the patients who have undergone surgical procedures, such as thoracotomy, pleurectomy, and video-assisted thoracoscopy. The patient presented here is the third reported case successfully treated with radiotherapy. Ventilation scintigraphy was used to localise the air leak, and localised radiotherapy was performed at the targeted location. After radiotherapy, the air leak ceased and at the 3-month followup, the pneumothorax had not recurred. Radiotherapy can be a treatment modality for patients with prolonged air leak, who are not candidates for surgery.

Endobronchial valves for persistent postoperative pulmonary air leak: accurate monitoring and functional implications

An alveolar-pleural fistula is a communication between the pulmonary parenchyma distal to a segmental bronchus and the pleural space. A postoperative pulmonary expiratory air leak after an anatomic pulmonary resection is usually managed conservatively. The use of endobronchial valves is a minimal invasive method that may be effective for the treatment of a persistent postoperative pulmonary air leak. We present and discuss the advantages of a digital thoracic drainage system for the accurate, objective and reproducible air leak assessment during endobronchial valve placement. Our case also illustrates that, even after lobectomy, lobar exclusion with valves allows air leak resolution without atelectasis and with moderate functional alteration. We discuss the anatomic and physiologic changes induced by valves placed for air leak closure.

Update on interventional bronchoscopy for the thoracic radiologist

Interventional bronchoscopy, together with other domains of interventional pulmonology, has experienced tremendous technological advances. Diagnostic applications include endobronchial ultrasound, which enables endoscopists to see through airway walls. White light videobronchoscopy, autofluorescence imaging, and narrow band imaging have enhanced the ability to detect early lung cancer at a preinvasive stage. Electromagnetic navigational bronchoscopy, ultrathin bronchoscopy, and virtual bronchoscopy increase the diagnostic yield of biopsy of small peripheral lung lesions. The options that are currently available for the relief of central airway obstruction are also numerous, with both flexible and rigid bronchoscopic applications. Stents, although dichotomized to silicone and metal, come in various sizes and shapes to suit the requirements of the pathology being treated. Ablative techniques are categorized into those with an immediate effect and those with a delayed effect. Laser, electrocautery, and argon plasma coagulation can immediately relieve obstruction and control hemoptysis, whereas cryosurgery, brachytherapy, and photodynamic therapy have established roles in subacute airway obstruction and in the treatment of early lung cancer. Microdebriders have recently been added to the armamentarium of modalities for mechanical debulking of tumor. Distal airway obstruction has also been targeted with bronchial thermoplasty treatment of refractory asthma and with bronchoscopic lung volume reduction for the management of severe emphysema. This array of new technology has fostered collaborative work with a wide range of other medical specialties to deliver safer, more effective, minimally invasive treatment.

Endobronchial valve migration

Endobronchial valves are increasingly used as a treatment modality as a less invasive alternative to lung volume reduction surgery in patients with severe emphysema. Endobronchial valves have also been used to treat patients with persistent pulmonary air leaks and those with bronchopleural fistulae. We report a case of a 61-year-old male with severe bullous emphysema. Following video-assisted thoracoscopic surgery and giant bullectomy, he had a persistent air leak. We inserted two endobronchial valves (in the lingular lobe and the anterior segment of the upper lobe) and the air leak ceased immediately. However, over the subsequent 5 months following the insertion of the endobronchial valves, the patient suffered recurrent chest infections and the endobronchial valves were found to have migrated to the orifice of the basal segment of the left lower lobe and the orifice of the basal segments of the right lower lobe.

Clinical evaluation of endoscopic bronchial occlusion with silicone spigots for the management of persistent pulmonary air leaks

OBJECTIVE

The aim of this study was to evaluate the clinical effectiveness of endoscopic bronchial occlusion (EBO) with endobronchial Watanabe spigots (EWSs), a type of silicone bronchial blocker, for managing prolonged pulmonary air leaks.

PATIENTS AND METHODS

Between October 2002 and April 2010, 24 patients with surgically incurable pulmonary air leaks underwent EBO with EWSs. The spigot was grasped with forceps and inserted into the affected bronchus by using a flexible bronchoscope through an endotracheal or a tracheostomy tube.

RESULTS

In each patient, at least one EWS (mean=2.8) was placed for air leaks due to pneumothorax (n=15), empyema (n=8), or postsurgical complications (n=1). Twelve patients (50%) had complete resolution of the air leaks and seven (29.2%) had a reduction in air leaks, but five (20.8%) showed no improvement. Twenty-three patients required thoracic drainage tubes, which were successfully removed after EBO in 15 patients (65.2%). Of the 24 patients, four experienced severe respiratory failure requiring mechanical ventilation but were successfully treated. Complications were spigot migration, atelectasis, pneumonia, and lung abscess, but none caused significant mortality.

CONCLUSION

EBO with EWSs seems to be a reasonable and manageable treatment option for patients with prolonged pulmonary air leaks, including those with severe respiratory failure requiring mechanical ventilation.

Bronchoscopic lung volume reduction

The application of lung volume reduction surgery in clinical practice is limited by high postoperative morbidity and stringent selection criteria. This has been the impetus for the development of bronchoscopic approaches to lung volume reduction. A range of different techniques such as endobronchial blockers, airway bypass, endobronchial valves, thermal vapor ablation, biological sealants, and airway implants have been employed on both homogeneous as well as heterogeneous emphysema. The currently available data on efficacy of bronchoscopic lung volume reduction are not conclusive and subjective benefit in dyspnoea scores is a more frequent finding than improvements on spirometry or exercise tolerance. Safety data are more promising with rare procedure-related mortality, few serious complications, and short hospital length of stay. The field of bronchoscopic lung volume reduction continues to evolve as ongoing prospective randomized trials build on earlier feasibility data to clarify the true efficacy of such techniques.

Endoscopic lung volume reduction effectively treats acute respiratory failure secondary to bullous emphysema

Emphysema often affects the lungs in a heterogeneous fashion, and collapse or removal of severely hyperinflated portions of lung can improve overall lung function and symptoms. The role of lung volume reduction (LVR) surgery in selected patients is well established, but that of non-surgical LVR is still being defined. In particular, use of endobronchial LVR is still under development. This case report describes a 48-year-old non-smoker with severe bullous emphysema complicated by acute hypercapnic respiratory failure, who was successfully treated by endobronchial valve placement while intubated in an intensive care unit.

Special situations: air leak after lung volume reduction surgery and in ventilated patients

Patients undergoing lung volume reduction surgery and those supported by mechanical ventilation are among our most vulnerable patients. Prolonged air leak in these fragile patients can have dire, even fatal, consequences. This article describes the incidence of prolonged air leak in these populations, the causes ascribed to their development, and strategies that may be applied to their prevention and treatment.

Emerging technologies for the thorax: indications, management and complications

The field of interventional pulmonology has rapidly expanded to include the management and treatment of complex diseases of the chest. The management of central airway obstruction, pleural disease diagnosis, treatment and palliation, advanced bronchoscopic techniques to aid in the diagnosis of lung cancer and innovative therapies to treat asthma and COPD have all emerged over the past decade. As astute clinicians, we are all aware of the risks and benefits of using these therapies to treat our patients. In order to appropriately treat and manage these often complex medical situations, the physician should have an expert knowledge of all available modalities, the expertise to safely perform the procedure and the ability to minimize the risk of and manage the associated complications that may arise. In this chapter we review and update some of the bronchoscopic and pleural interventions offered by interventional pulmonologists as well as the associated complications and management.

Emergency use of an endobronchial one-way valve in the management of severe air leak and massive subcutaneous emphysema

Bronchopleural (BPF) and alveolar-pleural (APF) fistulas are frequently encountered in clinical practice with persistent air leaks that can lead to significant morbidity, prolonged hospital stay, and potentially increased mortality. BPF and APF are commonly related to pulmonary resections. Other etiologies include minimally invasive procedures (thoracentesis and image-guided biopsies), and spontaneous fistulas related to an underlying structural lung disease (e.g., emphysema) or a necrotizing pulmonary process (e.g., infection or malignancy). Radiofrequency ablation for pulmonary malignancies is an effective modality that can rarely lead to APF with persistent air leak. Surgical intervention remains the standard treatment option for BPF and APF. A variety of minimally invasive bronchoscopic approaches can be considered for selected nonsurgical candidates. The use of one-way endobronchial valves to manage severe and persistent air leaks can be considered a minimally invasive option in selected patients. The valves selectively block inspiratory airflow to a specific segmental or subsegmental airway but allow expiratory flow with drainage of air and secretions from the corresponding distal airways and lung parenchyma.

Use of endobronchial one-way valves reveals questions on etiology of spontaneous pneumothorax: report of three cases

Spontaneous pneumothoraces are believed to arise when air from the supplying airway exit via a ruptured visceral pleural bleb into the pleural cavity. Endobronchial one-way valves (EBVs) allow air exit (but not entry) from individual segmental airways. Systematic deployment of EBVs was applied to three patients with secondary spontaneous pneumothoraces and persistent airleak. In all cases, balloon-catheter occlusion of the upper lobe bronchus stopped the airleak. EBVs applied to individual upper lobe segmental airways failed to terminate the airleak, which only stopped after placements of multiple EBVs to occlude all upper lobe segments. The observation questions the traditional belief of 'one-airway-one-bleb-one-leak' in spontaneous pneumothorax.