Intrabronchial valves for treatment of alveolar-pleural fistula in a patient with Pneumocystis jirovecii pneumonia

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.

Successful long-term treatment of persistent pulmonary air leak in pneumocystis jirovecii pneumonia by unidirectional endobronchial valves

Spontaneous pneumothorax is a rare complication of pneumocystis jirovecii pneumonia. We report a patient with pneumocystis jirovecii pneumonia and therapy-refractory, right-sided pneumothorax due to persistent air leak (PAL) despite prolonged chest tube placement and multiple pleurodesis attempts. Due to the patient's morbidity, we evaluated if the PAL can be sealed by unidirectional endobronchial valves (EBVs). After occlusion of the right upper lobe by a balloon catheter, the air leak flow-rate decreased from 800 ml/min to 250 ml/min. Zephyr EBVs (ZEBVs) were placed in the segmental right upper lobe bronchi and subsequently, a complete resolution of the pneumothorax was noted. During 30 months of follow-up, neither recurrence of pneumothorax nor any adverse events of EBV treatment were noted. We conclude that ZEBV placement might be an effective and well-tolerated treatment option for PAL secondary to pneumocystis jirovecii pneumonia with promising long-term results.

Bronchoscopic valves for prolonged air leak: current status and technique

Unidirectional airway valves are devices used for the treatment of persistent air leaks (PALs) secondary to alveolar-pleural fistulas (APF) or bronchopleural fistulas (BPFs). These valves were originally developed as a non-surgical alternative to lung volume reduction surgery (LVRS) for patients with chronic obstructive pulmonary disease (COPD). Randomized trials investigating the use of valves for bronchoscopic LVRS did not lead to the Federal Drug Administration (FDA) approval, but stemming from these studies a Humanitarian Device Exemption (HDE) was granted to Spiration intrabronchial valves (IBVs) for the treatment of PALs. These valves are being increasingly utilized due to the effectiveness of IBVSs in reducing PALs, thus shortening duration of hospitalizations and minimizing the risk of hospital associated complications. The literature supporting the use of unidirectional airway valves for the bronchoscopic treatment of PALs is grounded primarily in case reports. While the current body of literature available to justify the use of unidirectional valves is limited to case series, current multicenter, randomized trials should provide further guidance regarding patient selection and effectiveness.