Endobronchial valves in the treatment of persistent air leak, an alternative to surgery

Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis

BACKGROUND

Patients with persistent air leak (PAL) pose a therapeutic challenge to physicians, with prolonged hospital stays and high morbidity. There is little evidence on the efficacy and safety of bronchial valves (BV) for PAL.

METHODS

We systematically searched the PubMed and Embase databases to identify studies evaluating the efficacy and safety of BV for PAL. We calculated the success rate (complete resolution of air leak or removal of intercostal chest drain after bronchial valve placement and requiring no further procedures) of BV for PAL in individual studies. We pooled the data using a random-effects model and examined the factors influencing the success rate using multivariable meta-regression.

RESULTS

We analyzed 28 observational studies (2472 participants). The pooled success rate of bronchial valves in PAL was 82% (95% confidence intervals, 75 to 88; 95% prediction intervals, 64 to 92). We found a higher success rate in studies using intrabronchial valves versus endobronchial valves (84% vs. 72%) and in studies with more than 50 subjects (93% vs. 77%). However, none of the factors influenced the success rate of multivariable meta-regression. The overall complication rate was 9.1% (48/527). Granulation tissue was the most common complication reported followed by valve migration or expectoration and hypoxemia.

CONCLUSION

Bronchial valves are an effective and safe option for treating PAL. However, the analysis is limited by the availability of only observational data.

Algorithm for the Bronchoscopic Diagnosis of Alveolar-Pleural Fistula

Alveolar-pleural fistulas (APF) are a clinical entity that represents a diagnostic and therapeutic challenge.

OBJECTIVE

The objective of this work is to design a diagnostic algorithm for the anatomical detection of APF in patients who are not candidates for surgical treatment.

METHOD

Prospective non-randomized study of 47 patients. Diagnostic procedures were performed: (a) prior to bronchoscopy: computed axial tomography (CT) and implantation of electronic pleural drainage system (EPD) and (b) endoscopic: endobronchial occlusion (EO) by balloon, selective endobronchial oxygen insufflation (OI) (2l) and selective bronchography (BS) (instillation of iodinated radiological contrast using continuous fluoroscopy).

RESULTS

The sample was predominantly male (81%). The diagnostic methods revealed: (a) Determination of the anatomical location of APF by CT in 15/46 patients (31.9% of sample), and variations in the pattern (intermittent or continuous air leak) and quantification after drug administration sedatives using EPD, (b) endoscopic: anatomical determination of APF was achieved in 57.1, 81 and 63.4% respectively using EO, OI and BS. The combination of the diagnostic tests allowed us to determine the anatomical location of the APF in 91.5% of the sample. No complications were recorded in 85.1% of cases.

CONCLUSIONS

The diagnosis of APF by flexible bronchoscopy is a useful method, with an adequate safety and efficacy profile. The proposed diagnostic algorithm includes the use of EPD and performing a CT scan. Regarding endoscopic diagnosis: in case of continuous air leak, the first option is OE; and if the leak is intermittent, we recommend endobronchial OI, with BS as a secondary option (respective sensitivity 81% vs 63.4% and complications 8.1% vs 7.3%).

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States

INTRODUCTION

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9].

METHODS

We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States.

RESULTS

We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows.

DISCUSSION

This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Construction and validation of a nomogram for predicting prolonged air leak after minimally invasive pulmonary resection

Background

Prolonged air leak (PAL) remains one of the most frequent postoperative complications after pulmonary resection. This study aimed to develop a predictive nomogram to estimate the risk of PAL for individual patients after minimally invasive pulmonary resection.

Methods

Patients who underwent minimally invasive pulmonary resection for either benign or malignant lung tumors between January 2020 and December 2021 were included. All eligible patients were randomly assigned to the training cohort or validation cohort at a 3:1 ratio. Univariate and multivariate logistic regression were performed to identify independent risk factors. All independent risk factors were incorporated to establish a predictive model and nomogram, and a web-based dynamic nomogram was then built based on the logistic regression model. Nomogram discrimination was assessed using the receiver operating characteristic (ROC) curve. The calibration power was evaluated using the Hosmer-Lemeshow test and calibration curves. The nomogram was also evaluated for clinical utility by the decision curve analysis (DCA).

Results

A total of 2213 patients were finally enrolled in this study, among whom, 341 cases (15.4%) were confirmed to have PAL. The following eight independent risk factors were identified through logistic regression: age, body mass index (BMI), smoking history, percentage of the predicted value for forced expiratory volume in 1 second (FEV1% predicted), surgical procedure, surgical range, operation side, operation duration. The area under the ROC curve (AUC) was 0.7315 [95% confidence interval (CI): 0.6979–0.7651] for the training cohort and 0.7325 (95% CI: 0.6743–0.7906) for the validation cohort. The P values of the Hosmer-Lemeshow test were 0.388 and 0.577 for the training and validation cohorts, respectively, with well-fitted calibration curves. The DCA demonstrated that the nomogram was clinically useful. An operation interface on a web page (https://lirongyangql.shinyapps.io/PAL_DynNom/) was built to improve the clinical utility of the nomogram.

Conclusion

The nomogram achieved good predictive performance for PAL after minimally invasive pulmonary resection. Patients at high risk of PAL could be identified using this nomogram, and thus some preventive measures could be adopted in advance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02716-w.

Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery

PURPOSE

Air leaks are common after lobectomy, segmentectomy, and lung volume reduction surgery (LVRS). This can increase post-operative morbidity, cost, and hospital length of stay. The management of post-pulmonary resection air leaks remains challenging. Minimally invasive effective interventions are necessary. The Spiration Valve System (SVS, Olympus/Spiration Inc., Redmond, WA, US) is approved by the FDA under humanitarian use exemption for management of prolonged air leaks.

METHODS

This is a prospective multicenter registry of 39 patients with air leaks after lobectomy, segmentectomy, and LVRS managed with an intention to use bronchoscopic SVS to resolve air leaks.

RESULTS

Bronchoscopic SVS placement was feasible in 82.1% of patients (32/39 patients) and 90 valves were placed with a median of 2 valves per patient (mean of 2.7 ± 1.5 valves, range of 1 to 7 valves). Positive response to SVS placement was documented in 76.9% of all patients (30/39 patients) and in 93.8% of patients when SVS placement was feasible (30/32 patients). Air leaks ultimately resolved when SVS placement was feasible in 87.5% of patients (28/32 patients), after a median of 2.5 days (mean ± SD of 8.9 ± 12.4 days). Considering all patients with an intention to treat analysis, bronchoscopic SVS procedure likely contributed to resolution of air leaks in 71.8% of patients (28/39 patients). The post-procedure median hospital stay was 4 days (mean 6.0 ± 6.1 days).

CONCLUSIONS

This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.

Management of air leaks post-surgical lung resection

Airleaks are one of the most common complications associated with elective lung resection. There have been many techniques and modern advancements in thoracic surgery, however airleaks persist. This review article will discuss several interventions ranging from conservative noninvasive to surgical management of the persistent airleak. These techniques include stopping of suction on the plueravac, fibrin patches, pleurodesis, use of endobronchial valves (EBVs), return to OR for operative intervention, and lastly to send patients home with mini pleuravacs.

[Interventional treatment of tracheopleural and bronchopleural fistulas]

BACKGROUND

Interventional bronchoscopy is an indispensable option to manage bronchopleural and tracheopleural fistulas in patients in a poor general condition and at high risk for developing postoperative complications.

METHODS

This article is based on a search in the PubMed database for relevant publications and own experiences as surgeons and pneumologists.

RESULTS

Various interventional techniques can be used for the treatment of bronchopleural and tracheopleural fistulas. Currently, the insertion of stents or endobronchial valves is the most frequently used treatment. Ideally, the attending anesthesiologist will have experience with high frequency jet ventilation and the attending surgeon will have experience with rigid bronchoscopy, flexible bronchoscopy, and interventional bronchoscopy.

DISCUSSION

Due to a lack of standardized treatment recommendations, individual treatment plans must be decided according to the location of the bronchopleural or tracheopleural fistula and taking existing comorbidities into account.

Anaesthetic management for endobronchial valve insertion: lessons learned from a single centre retrospective series and a literature review

Background

Endoscopic lung volume reduction using one or more endobronchial valves is a treatment option for a select group of patients with severe emphysema. Patients presenting for this procedure pose various challenges to the anaesthetist; in addition to their lung condition, they are often elderly with multiple comorbidities. The procedure is usually performed outside the operating room. Monitored anaesthesia care with intravenous sedation, and general anaesthesia with an endotracheal tube have both been described for these procedures, aiming for adequate ventilation and haemodynamic stability.

Methods

We present our experience on 20 of these procedures in relation to the anaesthetic techniques employed and discuss the perioperative challenges involved in managing these cases.

Results

Twenty one planned endobronchial valve insertion procedures were identified on 18 patients. There were ten cases of monitored anaesthesia care with sedation and 10 cases which used general anaesthesia with an endotracheal tube. Two have been excluded; one had features of anaphylaxis and the procedure was abandoned, and the other required conversion from monitored anaesthesia care to general anaesthesia with endotracheal tube.

Conclusions

Both monitored anaesthesia care with sedation and general anaesthesia with endotracheal tube were well tolerated during endobronchial valve insertion procedures. General anaesthesia with endotracheal tube may offer better interventional conditions, patient comfort and reduced anaesthetic time.

Unidirectional endobronchial valves for management of persistent air-leaks: results of a multicenter study

Background

To evaluate the efficacy of Endo-Bronchial Valves in the management of persistent air-leaks (PALs) and the procedural cost.

Methods

It was a retrospective multicenter study including consecutive patients with PALs for alveolar pleural fistula (APF) undergoing valve treatment. We assessed the efficacy and the cost of the procedure.

Results

Seventy-four patients with persistent air leaks due to various etiologies were included in the analysis. In all cases the air leaks were severe and refractory to standard treatments. Sixty-seven (91%) patients underwent valve treatment obtaining a complete resolution of air-leaks in 59 (88%) patients; a reduction of air-leaks in 6 (9%); and no benefits in 2 (3%). The comparison of data before and after valve treatment showed a significant reduction of air-leak duration (16.2±8.8 versus 5.0±1.7 days; P<0.0001); chest tube removal (16.2±8.8 versus 7.3±2.7 days; P<0.0001); and length of hospital stay (LOS) (16.2±8.8 versus 9.7±2.8 days; P=0.004). Seven patients not undergoing valve treatment underwent pneumo-peritoneum with pleurodesis (n=6) or only pleurodesis (n=1). In only 1 (14%) patient, the chest drainage was removed 23 days later while the remaining 6 (86%) were discharged with a domiciliary chest drainage removed after 157±41 days. No significant difference was found in health cost before and after endobronchial valve (EBV) implant (P=0.3).

Conclusions

Valve treatment for persistent air leaks is an effective procedure. The reduction of hospitalization costs related to early resolution of air-leaks could overcome the procedural cost.

Endobronchial one-way valves for treatment of persistent air leaks: a systematic review

Persistent air leak (PAL) is associated with significant morbidity and mortality, prolonged hospitalization and increased health-care costs. It can arise from a number of conditions, including pneumothorax, necrotizing infection, trauma, malignancies, procedural interventions and complications after thoracic surgery. Numerous therapeutic options, including noninvasive and invasive techniques, are available to treat PALs. Recently, endobronchial one-way valves have been used to treat PAL. We conducted a systematic review based on studies retrieved from PubMed, EMbase and Cochrane library. We also did a hand-search in the bibliographies of relevant articles for additional studies. 34 case reports and 10 case series comprising 208 patients were included in our review. Only 4 patients were children, most of the patients were males. The most common underlying disease was COPD, emphysema and cancer. The most remarkable cause was pneumothorax. The upper lobes were the most frequent locations of air leaks. Complete resolution was gained within less than 24 h in majority of patients. Complications were migration or expectoration of valves, moderate oxygen desaturation and infection of related lung. No death related to endobronchial one-way valves implantation has been found. The use of endobronchial one-way valve adds to the armamentarium for non-invasive treatments of challenging PAL, especially those with difficulties of anesthesia, poor condition and high morbidity. Nevertheless, prospective randomized control trials with large sample should be needed to further evaluate the effects and safety of endobronchial one-way valve implantation in the treatment of PAL.

[Absence of postoperative pulmonary impermeability in patients with spontaneous pneumothorax]

AIM

to improve treatment of patients with spontaneous pneumothorax who had not postoperative pulmonary impermeability.

MATERIAL AND METHODS

87 patients with spontaneous pneumothorax underwent videothoracoscopy (VTS), lung resection supplemented by pleurodesis (parietal pleurectomy or pleural abrasion). Absence of pulmonary impermeability was observed in 5 (5.7%) patients.

RESULTS AND DISCUSSION

Re-operation was performed in 2 patients (Vanderschuren 2 and 3) namely re-thoracoscopy and thoracotomy with additional ligation of air origins. Drainage tubes were removed in 4 and 17 days postoperatively in patient without/with emphysema respectively. In patient (Vanderschuren 1) who underwent thoracoscopic resection and parietal pleural abrasion valve bronchoblocation was performed in 9 days after VTS due to persistent pneumothorax. Pleural drainage tube was removed in 13 days (emphysema) after bronchial valve deployment. 2 patients (Vanderschuren 4) had heterogeneous pulmonary emphysema. One of them underwent video-assisted mini-thoracotomy, lung resection with reinforcement of seams with synthetic material. In other observation conversion to thoracotomy followed by atypical resection of bullous emphysema and manual suturing of lung was applied. In both cases bronchoblocation was performed intraoperatively with good results. Drainage tubes were removed in 13 and 17 days respectively. There were no complications.

CONCLUSION

Intraoperative endoscopic bronchoblocation is advisable if air leakage is considerable in operating theater and complicates lung smoothing. Such approach reduces hospital-stay and improves outcomes.

Intrabronchial Valve Treatment for Prolonged Air Leak: Can We Justify the Cost?

Background. Prolonged air leak is defined as an ongoing air leak for more than 5 days. Intrabronchial valve (IBV) treatment is approved for the treatment of air leaks. Objective. To analyze our experience with IBV and valuate its cost-effectiveness. Methods. Retrospective analysis of IBV from June 2013 to October 2014. We analyzed direct costs based on hospital and operating room charges. We used average costs in US dollars for the analysis not individual patient data. Results. We treated 13 patients (9 M/4 F), median age of 60 years (38 to 90). Median time from diagnosis to IBV placement was 9.8 days, time from IBV placement to chest tube removal was 3 days, and time from IBV placement to hospital discharge was 4 days. Average room and board costs were $14,605 including all levels of care. IBV cost is $2750 per valve. The average number of valves used was 4. Total cost of procedure, valves, and hospital stay until discharge was $13,900. Conclusion. In our limited experience, the use of IBV to treat prolonged air leaks is safe and appears cost-effective. In pure financial terms, the cost seems justified for any air leak predicted to last greater than 8 days.