Intrabronchial Pneumonectomy for Vanishing Lung Syndrome: First Reported Case

Vanishing Lung Syndrome: A Case Report and Systematic Review of the Literature

Vanishing lung syndrome (VLS), also known as idiopathic giant bullous emphysema, is defined by the emergence of sizable bullae causing compression on healthy lung tissue. The elusive etiology of VLS mandates a diagnosis based on radiographic evidence showcasing giant bullae occupying at least one-third of the hemithorax in one or both lungs. This report presents a case of VLS in a 36-year-old female smoker devoid of any prior medical history. Additionally, we conducted a systematic review to discern the demographics, risk factors, and treatment modalities for individuals diagnosed with VLS.

Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience

BACKGROUND

Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes.

METHODS

In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction.

RESULTS

Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients.

CONCLUSION

PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

Bronchopleural Fistula in the Mechanically Ventilated Patient: A Concise Review

OBJECTIVE

To describe the physiology of air leak in bronchopleural fistula in mechanically ventilated patients and how understanding of its physiology drives management of positive-pressure ventilation. To provide guidance of lung isolation, mechanical ventilator, pleural catheter, and endobronchial strategies for the management of bronchopleural fistula on mechanical ventilation.

DATA SOURCES

Online search of PubMed and manual review of articles (laboratory and patient studies) was performed.

STUDY SELECTION

Articles relevant to bronchopleural fistula, mechanical ventilation in patients with bronchopleural fistula, independent lung ventilation, high-flow ventilatory modes, physiology of persistent air leak, extracorporeal membrane oxygenation, fluid dynamics of bronchopleural fistula airflow, and intrapleural catheter management were selected. Randomized trials, observational studies, case reports, and physiologic studies were included.

DATA EXTRACTION

Data from selected studies were qualitatively evaluated for this review. We included data illustrating the physiology of driving pressure across a bronchopleural fistula as well as data, largely from case reports, demonstrating management and outcomes with various ventilator modes, intrapleural catheter techniques, endoscopic placement of occlusion and valve devices, and extracorporeal membrane oxygenation. Themes related to managing persistent air leak with mechanical ventilation were reviewed and extracted.

DATA SYNTHESIS

In case reports that demonstrate different approaches to managing patients with bronchopleural fistula requiring mechanical ventilation, common themes emerge. Strategies aimed at decreasing peak inspiratory pressure, using lower tidal volumes, lowering positive end-expiratory pressure, decreasing the inspiratory time, and decreasing the respiratory rate, while minimizing negative intrapleural pressure decreases airflow across the bronchopleural fistula.

CONCLUSIONS

Mechanical ventilation and intrapleural catheter management must be individualized and aimed at reducing air leak. Clinicians should emphasize reducing peak inspiratory pressures, reducing positive end-expiratory pressure, and limiting negative intrapleural pressure. In refractory cases, clinicians can consider lung isolation, independent lung ventilation, or extracorporeal membrane oxygenation in appropriate patients as well as definitive management with advanced bronchoscopic placement of valves or occlusion devices.

Giant bullous emphysema mistaken for traumatic pneumothorax

INTRODUCTION

Giant bullous emphysema (GBE) is defined by giant bullae in one or both upper lobes, occupying at least one-third of the hemithorax and compressing the surrounding parenchyma [1]. Symptoms include dyspnea, hypoxia, chest pain and pressure, and hemoptysis [2], which can be complicated by pneumothorax and infection of the bullae [3].

CASE PRESENTATION

A 50-year-old male was brought to the emergency department after he fell 5 m in a suicide attempt. The patient was in respiratory distress and had bilateral absence of breath sounds. He was intubated and bilateral chest tubes were inserted. A computerized tomography (CT) scan showed bilateral giant bullous emphysema in the upper lobes, confirming a diagnosis of GBE. As a result of the insertion of chest tubes, he developed bilateral high flow fistulas. During his hospitalization, he developed sepsis secondary to ventilator-associated pneumonia. In an attempt to control the fistulas, a right bullectomy was performed. Despite antibiotic treatment and surgical intervention, the patient died due to septic shock.

DISCUSSION

The clinical picture of a patient with GBE can be similar to that of pneumothorax, and GBE has been reported as being misdiagnosed as pneumothorax [4,5]. A CT scan can play an important role in differentiating these conditions [6], thus avoiding needle decompression, which can be catastrophic [6].

CONCLUSION

Giant bullous emphysema can represent a pitfall in trauma assessment. We recommend that in cases where pneumothorax is suspected, if the patient is clinically stable, imaging studies should be performed prior to chest tube placement.

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.