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

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%).

Evaluation and management of persistent air leak

INTRODUCTION

Persistent air leaks (PAL) represent a challenging clinical problem for which there is not a clear consensus to guide optimal management. PAL is associated with significant morbidity, mortality, and increased length of hospital stay. There are a variety of surgical and non-surgical management options available.

AREAS COVERED

This narrative review describes the current evidence for PAL management including surgical approach, autologous blood patch pleurodesis, chemical pleurodesis, endobronchial valves, and one-way valves. Additionally, emerging topics such as drainage-dependent air leak and intensive care unit management are described.

EXPERT OPINION

There has been considerable progress in understanding the pathophysiology of PAL and growing evidence to support the various non-surgical treatment modalities. Increased recognition of drainage-dependent persistent air leaks offers the opportunity to decrease the number of patients requiring additional invasive treatment. Randomized control trials are needed to guide optimal management.

Prevention of pulmonary air leaks using a biodegradable tissue-adhesive fiber sheet based on Alaska pollock gelatin modified with decanyl groups

Tissue adhesives have been widely used in surgery to treat pulmonary air leaks. However, conventional adhesives have poor interfacial strength under wet conditions. To overcome this clinical problem, we modified Alaska pollock-derived gelatin to include decanyl (C10) groups (C10-ApGltn) and used electrospinning to create a tissue-adhesive fiber sheet (AdFS). C10-AdFS showed higher burst strength when adhering to porcine pleura compared with a sheet of original ApGltn (Org-ApGltn). Hematoxylin-eosin-stained sections after burst experiments reveal that a dense C10-AdFS layer remained on the surface of the porcine pleura. The effect of the degree of C10 modification of ApGltn on the burst strength was evaluated. ApGltn with a C10 modification ratio of 13 mol% amino groups (13C10-AdFS) exhibited the highest burst strength. Furthermore, from ex vivo experiments with extracted rat lung, 13C10-AdFS exhibited a higher burst strength (41 cm H₂O) than Org-AdFS. The decanyl groups in 13C10-AdFS interacted with the hydrophobic proteins and the lipid bilayers of the cells, resulting in the high interfacial strength between 13C10-AdFS and the pleura. Moreover, 13C10-AdFS samples implanted subcutaneously in the backs of rats were completely degraded within 21 days without any severe inflammation. These results show that 13C10-AdFS is a promising adhesive material for the treatment of pulmonary air leaks.

Endobronchial Valves for the Treatment of Bronchopleural Fistula and Pneumothorax Caused by Pulmonary Cryptococcosis in an AIDS Patient

Cryptococcal disease is an opportunistic infection that occurs primarily among people with advanced HIV disease and is an important cause of morbidity and mortality. Spontaneous pneumothorax (SP) is rare in acquired immune deficiency syndrome (AIDS) patients with pulmonary cryptococcosis (PC), but when it occurs, rapid and effective treatment is crucial to the prognosis, with mortality rates varying from 30 to 60%. SP is related to pneumonia mainly due to bacterial infections and pneumocystic jirovecii pneumonia (PJP). However, SP caused by PC is rare. When it occurs, it is often fatal and refractory, which is a challenge both for patients and clinicians. Here, we report a case of SP during the treatment of cryptococcal disease in a patient with AIDS. The pneumothorax remained despite chest tube drainage and evolved into a bronchopleural fistula that was confirmed by the Chartis system. The pneumothorax was significantly resolved following the placement of 2 endobronchial valves (EBVs). The patient tolerated the procedure very well and the pneumothorax gradually resolved. When immunocompromised patients suffer from refractory pneumothorax or prolonged air leaks, EBV implantation may be a feasible and minimally invasive procedure for this vulnerable population.

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.

Persistent air leaks: a review with an emphasis on bronchoscopic management

Persistent air leak (PAL) is a cause of significant morbidity in patients who have undergone lung surgery and those with significant parenchymal lung disease suffering from a pneumothorax. Its management can be complex and challenging. Although conservative treatment with chest drain and observation is usually effective, other invasive techniques are needed when conservative treatment fails. Surgical management and medical pleurodesis have long been the usual treatments for PAL. More recently numerous bronchoscopic procedures have been introduced to treat PAL in those patients who are poor candidates for surgery or who decline surgery. These techniques include bronchoscopic use of sealants, sclerosants, and various types of implanted devices. Recently, removable one-way valves have been developed that are able to be placed bronchoscopically in the affected airways, ameliorating air-leaks in patients who are not candidates for surgery. Future comparative trials are needed to refine our understanding of the indications, effectiveness, and complications of bronchoscopic techniques for treating PAL. The following article will review the basic principles of management of PAL particularly focusing on bronchoscopic techniques.

The past, current and future of diagnosis and management of pleural disease

Pleural disease is frequently encountered by the chest physician. Pleural effusions arise as the sequelae of underlying disease processes including pressure/volume imbalances, infection and malignancy. In addition to pleural effusions, persistent air leaks after surgery and bronchopleural fistulae remain a challenge. Our understanding of pleural disease including its diagnosis and management, have made tremendous strides. The introduction of the molecular detection of organism specific infection, risk stratification and improvements in the non-surgical treatment of patients with pleural infection are all within reach and may be the standard of care in the very near future. Malignant pleural effusion management continues to evolve with the introduction of tunneled pleural catheters and procedures combining that and chemical pleurodesis. These advances in the diagnostic and therapeutic evaluation of pleural disease as well as what seems to be an increasing multidisciplinary interest in the space foretell a bright future.

Use of endobronchial valve insertion to treat relapsing pneumothorax: a case report and literature review

Backgorund and Aims: Unidirectional endobronchial valves have recently been shown to be beneficial as treatment for persistent air leaks. This report presents a first case of endobronchial valve implantation to treat relapsing pneumothorax in a Chinese patient, and also presents a review of the literature on the use of one-way valve insertion for the treatment of persistent air leaks.

METHODS

The patient did undergo a recent but failed chest tube intervention. By bronchoscopy and using Chartis® system measurements, the upper left lobe (including the left apical bronchus) was closed using a catheter.

RESULTS

After the expected decrease in airflow following bronchial occlusion, increased air pressure and decreased spilled air were noted; it was concluded that the pneumothorax was located in the left upper lobe. A Zephyr^® endobronchial valve was placed in the left upper apical bronchus. The health benefits of the procedure were noticed in the following days.

CONCLUSION

Our review suggests that the use of endobronchial valves could be used as an effective, minimally invasive, low-risk intervention for patients with pneumothorax that cannot be treated surgically.