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

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.

Management of Prolonged Pulmonary Air Leaks With Endobronchial Valve Placement

Background:

Prolonged pulmonary air leaks (PALs) are associated with increased morbidity and extended hospital stay. We sought to investigate the role of bronchoscopic placement of 1-way valves in treating this condition.

Methods:

We queried a prospectively maintained database of patients with PAL lasting more than 7 days at a tertiary medical center. Main outcome measures included duration of chest tube placement and hospital stay before and after valve deployment.

Results:

Sixteen patients were eligible to be enrolled from September 2012 through December 2014. One patient refused to give consent, and in 4 patients, the source of air leak could not be identified with bronchoscopic balloon occlusion. Eleven patients (9 men; mean age, 65 ± 15 years) underwent bronchoscopic valve deployment. Eight patients had postoperative PAL and 3 had a secondary spontaneous pneumothorax. The mean duration of air leak before valve deployment was 16 ± 12 days, and the mean number of implanted valves was 1.9 (median, 2). Mean duration of hospital stay before and after valve deployment was 18 and 9 days, respectively (P = .03). Patients who had more than a 50% decrease in air leak on digital monitoring had the thoracostomy tube removed within 3–6 days. There were no procedural complications related to deployment or removal of the valves.

Conclusions:

Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PAL. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage

BACKGROUND

A persistent air leak represents significant clinical management problems, potentially affecting morbidity, mortality, and health care costs. In 2008, a unidirectional, intrabronchial valve received humanitarian device exemption for use in managing prolonged air leak after pulmonary resection. Since its introduction, numerous reports exist but no large series describe current utilization or outcomes. Our aim was to report current use of intrabronchial valves for air leaks and review outcome data associated with its utilization.

METHODS

A multicenter, retrospective review of intrabronchial valve utilization from January 2013 to August 2014 was performed at eight centers. Data regarding demographics, valve utilization, and outcomes were analyzed.

RESULTS

We identified 112 patients undergoing evaluation for intrabronchial valve placement, with 67% (75 of 112) undergoing valve implantation. Nearly three quarters of patients underwent valve placement for off-label usage (53 of 75). A total of 195 valves were placed in 75 patients (mean 2.6 per patient; range, 1 to 8) with median time to air leak resolution of 16 days (range, 2 to 156).

CONCLUSIONS

We present the largest, multicenter study of patients undergoing evaluation for intrabronchial valve use for air leak management. Our data suggest the majority of intrabronchial valve placements are occurring for off-label indications. Although the use of intrabronchial valves are a minimally invasive intervention for air leak management, the lack of rigorously designed studies demonstrating efficacy remains concerning. Prospective randomized controlled studies remain warranted.

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.

Endobronchial valves in treatment of persistent air leaks: a systematic review of clinical evidence

Background

Persistent air leak is one of the most common complications of lung diseases and pulmonary resections. Prolonged hospitalization, increased morbidity, and increased overall treatment costs arise from persistent air leaks. The use of endobronchial valves (EBVs) in the management of air leaks is an important alternative, especially for patients who are not candidates for surgical treatment.

Material/Methods

We retrieved the included studies by performing a systematic search in PubMed and Scopus databases. The references of the included studies were also hand-searched.

Results

We retrieved 25 case reports and 3 case series from our literature search. The most common cause of persisting air leaks was spontaneous secondary pneumothorax (12/39, 31%). The left upper lobe (13/39, 33%) and right upper lobe (14/39, 36%) were the most frequent locations of air leaks. Most air leaks treated with EBVs ceased in less than 24 h. Three recurrences of air leak were reported and 2 cases of EBV migration were described. No deaths were reported in correlation with EBVs.

Conclusions

EBVs are a minimally invasive therapeutical option that may be suitable for the treatment of persistent air leaks regardless of the initial cause, especially in high-risk patients. Nevertheless, studies with better methodological quality are essential to standardize this technique and to provide more evidence on EBV safety issues.

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

INTRODUCTION

Persistent air leak is frustrating for both patients and physicians, above all leaks with a high risk of surgery. Insertion of endobronchial valves could be an alternative to surgery. The aim of this study is to describe our experience in these valves and analyse their efficacy in a series of patients with persistent air leaks.

MATERIAL AND METHODS

The valves are inserted by means of flexible bronchoscopy under conscious sedation and local anesthesia. A preliminary bronchoscopy identifies the air leak by bronchial occlusion using a balloon catheter. A successful outcome is defined as complete disappearance of the leak following removal of the chest drain, without the need for further surgery.

RESULTS

From November 2010 to December 2013, 8 patients with persistent air leaks were treated with endobronchial valves. The number of valves used ranged from 1 to 4 (median 2), with a median duration of air leak prior to placement of 15.5 days. There were no complications and the resolution of the leak was complete in 6 of 8 patients (75%). The median duration of drainage after insertion of the valves was 13 days and the median time to removal of 52.5 days.

CONCLUSIONS

Insertion of endobronchial valves is a safe and effective method for treating persistent air leaks, and a valid alternative to surgery.

Endobronchial valves in the management of recurrent haemoptysis

Minimally invasive treatment modalities for life-threatening haemoptysis in patients unresponsive to medical interventions and/or in patients deemed functionally inoperable are limited. We describe the implantation of endobronchial valves in a patient with recurrent haemoptysis, which presents both a novel indication for the use of these devices and a novel intervention for haemoptysis. Our patient is a 30-year-old male who developed bilateral upper lobe aspergillomata following previous pulmonary tuberculosis. The patient had a history of multiple hospitalisations for life-threating haemoptysis despite repeated bronchial artery embolisations. He was deemed to be inoperable given the bilateral nature of his disease and very poor pulmonary reserves. We proceeded to identify the segments involved with the aid of computed tomography reconstruction and implanted 3 endobronchial valves. Our patient remained haemoptysis free for 6 months and experienced no stent-related complications. Moreover, he was subsequently employed as a manual labourer and showed significant improvements in his functional capacity. Endobronchial valves may therefore represent a viable medium-term treatment option as a blockade device in patients unresponsive to medical interventions and/or in patients deemed functionally inoperable. Prospective studies are indicated to better delineate the role of endobronchial valves in this setting.