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Podder S, Khan M, Sink Z, Verga S, Kurman JS, Malsin E. Bronchoscopic Lung Volume Reduction: A Review. Semin Respir Crit Care Med 2024. [PMID: 39025124 DOI: 10.1055/s-0044-1787876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
Bronchoscopic lung volume reduction (BLVR) is an established treatment modality for the management of advanced chronic obstructive pulmonary disease complicated by severe emphysema and hyperinflation refractory to other therapies. BLVR aims to reduce hyperinflation and residual volume, thereby improving pulmonary function, symptom control, and quality of life. Multiple distinct devices and technologies, including endobronchial coils, thermal vapor ablation, bio-lung volume reduction, and airway bypass stenting, have been developed to achieve lung volume reduction with varying degrees of accessibility and evidence. The most promising BLVR treatment modality to date has been the placement of one-way endobronchial valves (EBVs), with more than 25,000 cases performed worldwide. Identifying symptomatic patients who would benefit from BLVR is challenging and can be time and resource intensive, and candidacy may be limited by physiologic parameters. Additional new technologies may be able to improve the identification and evaluation of candidates as well as increase the portion of evaluated patients who ultimately qualify for BLVR. In this review, we aim to provide historical context to BLVR, summarize the available evidence regarding its use, discuss potential complications, and provide readers with a clear guide to patient selection and referral for BLVR, with a focus on EBV placement. In addition, we will highlight potential future directions for the field.
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Affiliation(s)
- Shreya Podder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marium Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Zane Sink
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, North Carolina
| | - Steven Verga
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin
| | - Jonathan S Kurman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin
| | - Elizabeth Malsin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Froedtert Memorial Lutheran Hospital, Milwaukee, Wisconsin
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Damaraju V, Sehgal IS, Muthu V, Prasad KT, Dhooria S, Aggarwal AN, Agarwal R. Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis. J Bronchology Interv Pulmonol 2024; 31:e0964. [PMID: 38716831 DOI: 10.1097/lbr.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/05/2024] [Indexed: 05/24/2024]
Abstract
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.
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Affiliation(s)
- Vikram Damaraju
- Department of Pulmonary Medicine, All India Institute of Medical Sciences, Mangalagiri
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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De Vega Sanchez B, Disdier Vicente C, Lopez Pedreira MR, Matilla Gonzalez JM. Algorithm for the Bronchoscopic Diagnosis of Alveolar-Pleural Fistula. Arch Bronconeumol 2024:S0300-2896(24)00237-0. [PMID: 38987114 DOI: 10.1016/j.arbres.2024.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/12/2024]
Abstract
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%).
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Affiliation(s)
- Blanca De Vega Sanchez
- Respiratory Medicine Department, Interventional Pulmonology Unit, Hospital Clinico Universitario Valladolid, Spain.
| | - Carlos Disdier Vicente
- Respiratory Medicine Department, Interventional Pulmonology Unit, Hospital Clinico Universitario Valladolid, Spain
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Kent MS, Mitzman B, Diaz-Gutierrez I, Khullar OV, Fernando HC, Backhus L, Brunelli A, Cassivi SD, Cerfolio RJ, Crabtree TD, Kakuturu J, Martin LW, Raymond DP, Schumacher L, Hayanga JWA. The Society of Thoracic Surgeons Expert Consensus Document on the Management of Pleural Drains After Pulmonary Lobectomy: Expert Consensus Document. Ann Thorac Surg 2024:S0003-4975(24)00342-4. [PMID: 38723882 DOI: 10.1016/j.athoracsur.2024.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 03/16/2024] [Accepted: 04/16/2024] [Indexed: 07/04/2024]
Abstract
The Society of Thoracic Surgeons Workforce on Evidence-Based Surgery provides this document on management of pleural drains after pulmonary lobectomy. The goal of this consensus document is to provide guidance regarding pleural drains in 5 specific areas: (1) choice of drain, including size, type, and number; (2) management, including use of suction vs water seal and criteria for removal; (3) imaging recommendations, including the use of daily and postpull chest roentgenograms; (4) use of digital drainage systems; and (5) management of prolonged air leak. To formulate the consensus statements, a task force of 15 general thoracic surgeons was invited to review the existing literature on this topic. Consensus was obtained using a modified Delphi method consisting of 2 rounds of voting until 75% agreement on the statements was reached. A total of 13 consensus statements are provided to encourage standardization and stimulate additional research in this important area.
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Affiliation(s)
- Michael S Kent
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Brian Mitzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | | | - Onkar V Khullar
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Hiran C Fernando
- Division of Thoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania
| | - Leah Backhus
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Alessandro Brunelli
- Department of Thoracic Surgery, St James's University Hospital, Leeds, United Kingdom
| | - Stephen D Cassivi
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert J Cerfolio
- Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Traves D Crabtree
- Division of Thoracic Surgery, Southern Illinois University, Springfield, Illinois
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Linda W Martin
- Division of Thoracic Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lana Schumacher
- Division of Thoracic Surgery, Tufts Medical Center, Boston, Massachusetts
| | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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Taniguchi J, Aso S, Taisuke J, Matsui H, Fushimi K, Yasunaga H. Endobronchial silicone spigot in prolonged air leaks: Nationwide study on outcomes and risk factors for treatment failure. Respir Investig 2024; 62:449-454. [PMID: 38522361 DOI: 10.1016/j.resinv.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/22/2024] [Accepted: 03/07/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The endobronchial silicone spigot, also known as the endobronchial Watanabe spigot, is used in bronchoscopic interventions to manage prolonged pulmonary air leakage. However, the outcomes of this procedure have not been thoroughly investigated. METHODS Using a Japanese national inpatient database from April 2014 to March 2022, we assessed the clinical characteristics and outcomes of all eligible patients who received the endobronchial spigot. We also investigated risk factors associated with treatment failure. Treatment failure was defined as in-hospital death or the need for surgery after bronchial occlusion. RESULTS We analyzed data of 1095 patients who underwent bronchial occlusion using the endobronchial spigot. Among them, 252 patients (23.0%) died during hospitalization, and 403 patients (36.8%) experienced treatment failure. Factors associated with treatment failure included age between 85 and 94 years (odds ratio [OR] 1.83; 95% confidence intervals [CI], 1.04-3.21); male sex (OR 2.43; 95% CI, 1.44-4.11); low Barthel index score; comorbidities of interstitial pneumonia (OR 1.71; 95% CI, 1.18-2.48); antibiotics treatment (OR 1.45; 95% CI, 1.02-2.07); steroids treatment (OR 1.59; 95% CI, 1.07-2.36); and surgery prior to bronchial occlusion (OR 2.08; 95% CI, 1.29-3.35). In contrast, pleurodesis after bronchial occlusion (OR 0.49; 95% CI, 0.32-0.75), and admission to high-volume hospitals were inversely associated with treatment failure (OR 0.58; 95% CI, 0.37-0.90). CONCLUSIONS The endobronchial Watanabe spigot could be a nonsurgical treatment option for patients with prolonged pulmonary air leaks. Our findings will help identify patients who may benefit from such bronchial interventions.
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Affiliation(s)
- Jumpei Taniguchi
- Department of Clinical Epidemiology and Health Economics School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Shotaro Aso
- Department of Real World Evidence, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Jo Taisuke
- Department of Clinical Epidemiology and Health Economics School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics School of Public Health, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Martinez AF, Tom Z, Hsia DW, Vintch J, Yee N. Novel Insights from Clinical Practice Autologous Blood Patch Pleurodesis and Endobronchial Valves for Management of Persistent Air Leaks in Two Cases of Tuberculosis. Respiration 2024; 103:289-294. [PMID: 38417419 DOI: 10.1159/000537992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/14/2024] [Indexed: 03/01/2024] Open
Abstract
INTRODUCTION Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate. CASE PRESENTATION Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves. CONCLUSION The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients.
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Affiliation(s)
- Aida F Martinez
- Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, California, USA,
| | - Zachary Tom
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of California Irvine, Irvine, California, USA
| | - David W Hsia
- Division of Respiratory and Critical Care Physiology and Medicine, Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Janine Vintch
- Division of Respiratory and Critical Care Physiology and Medicine, Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Nathan Yee
- Division of Respiratory and Critical Care Physiology and Medicine, Department of Internal Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, California, USA
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Watanabe T, Yamauchi Y, Takeyama R, Kohmaru S, Dejima H, Saito Y, Sakao Y. A Comparison of the Efficacies of OK-432 and Talc Slurry for Pleurodesis in Patients with Prolonged Air Leak after Pulmonary Resection. Ann Thorac Cardiovasc Surg 2024; 30:n/a. [PMID: 37648484 PMCID: PMC10902650 DOI: 10.5761/atcs.oa.23-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
Abstract
PURPOSE A prolonged air leak (PAL) is one of the common postoperative complications of pulmonary resection. The aim of this study was to evaluate the efficacy and safety of pleurodesis with sterile talc or OK-432 for postoperative air leak. METHODS Patients with postoperative air leak who received chemical pleurodesis using sterile talc or OK-432 were retrospectively identified from medical records data. For pleurodesis with either agent, prior assessment and approval by the hospital safety department were carried out for each case, in addition to individual consent. RESULTS Between February 2016 and June 2022, 39 patients had PALs and underwent chemical pleurodesis. Among them, 24 patients received pleurodesis with talc (Talc group) and 15 with OK-432 (OK-432 group). The leak resolved after less than two pleurodesis treatments in 22 patients (91.7%) in the Talc group compared with 14 patients (93.3%) in the OK-432 group. Pleurodesis significantly increased white blood cell counts, C-reactive protein concentration, and body temperature in the OK-432 group compared with that in the Talc group (p <0.001, p = 0.003, and p <0.001, respectively). CONCLUSIONS Pleurodesis with talc may be an effective treatment option for postoperative air leak. Our findings suggest that talc was as effective as OK-432 and resulted in a milder systemic inflammatory response.
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Affiliation(s)
- Tomohiro Watanabe
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshikane Yamauchi
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Ryo Takeyama
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Shinya Kohmaru
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hitoshi Dejima
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yuichi Saito
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Yukinori Sakao
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
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Shorthose M, Barton E, Walker S. The contemporary management of spontaneous pneumothorax in adults. Breathe (Sheff) 2023; 19:230135. [PMID: 38229681 PMCID: PMC10790175 DOI: 10.1183/20734735.0135-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/12/2023] [Indexed: 01/18/2024] Open
Abstract
Spontaneous pneumothorax is a common presentation, and there has been a recent surge of research into the condition. With the recent publication of the new British Thoracic Society guidelines and the upcoming European Respiratory Society guidelines, we provide a concise up-to-date summary of clinical learning points. In particular we focus on the role of conservative or ambulatory management, as well as treatment options for persistent air leak and guidance for when to refer to thoracic surgeons for the prevention of the recurrence of pneumothorax. Educational aims To give up-to-date guidance on the acute management of spontaneous pneumothorax, including the role of conservative or ambulatory managementTo discuss the different treatment options for persistent air leak.To guide physicians on when to refer patients to thoracic surgeons for the prevention of the recurrence of pneumothorax.
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Affiliation(s)
| | - Eleanor Barton
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
| | - Steven Walker
- Academic Respiratory Unit, North Bristol NHS Trust, Bristol, UK
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Campos JH. Hypoxemia May Occur After Endobronchial Valve Deployment-The Mechanism Is Speculative at Present. J Cardiothorac Vasc Anesth 2023; 37:2116-2118. [PMID: 37633740 DOI: 10.1053/j.jvca.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Javier H Campos
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa.
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10
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Omballi M, Noori Z, Alanis RV, Lukken Imel R, Kheir F. Chartis-guided Endobronchial Valves Placement for Persistent Air Leak. J Bronchology Interv Pulmonol 2023; 30:398-400. [PMID: 36877223 DOI: 10.1097/lbr.0000000000000914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/07/2023] [Indexed: 03/07/2023]
Affiliation(s)
- Mohamed Omballi
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH
| | - Zaid Noori
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH
| | - Regina V Alanis
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Robert Lukken Imel
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH
| | - Fayez Kheir
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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11
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Hartigan PM. Hypoxemia and Endobronchial Valves. J Cardiothorac Vasc Anesth 2023; 37:2114-2115. [PMID: 37188585 DOI: 10.1053/j.jvca.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Philip M Hartigan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women's Hospital, Boston, Massachusetts.
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12
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Duron G, Backer E, Feller-Kopman D. Evaluation and management of persistent air leak. Expert Rev Respir Med 2023; 17:865-872. [PMID: 37855445 DOI: 10.1080/17476348.2023.2272701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/16/2023] [Indexed: 10/20/2023]
Abstract
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.
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Affiliation(s)
- Garret Duron
- Department of Pulmonary and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Elliot Backer
- Dartmouth-Hitchcock Medical Center, Department of Pulmonary and Critical Care Medicine, 1 Medical Center Drive, Lebanon, NH, Lebanon
| | - David Feller-Kopman
- Dartmouth-Hitchcock Medical Center, Department of Pulmonary and Critical Care Medicine, 1 Medical Center Drive, Lebanon, NH, Lebanon
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Barton EC, Maskell NA, Walker SP. Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023. [PMID: 37321247 DOI: 10.1055/s-0043-1769615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.
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Affiliation(s)
- Eleanor C Barton
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Nick A Maskell
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
| | - Steven P Walker
- Academic Respiratory Unit, North Bristol National Health Service Trust, Bristol, United Kingdom
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14
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Ahmed M, Dunn M, Kurland G, Burg G. Bronchoscopic blood patch in postlung transplant patients with persistent air leak. Pediatr Pulmonol 2023. [PMID: 37144871 DOI: 10.1002/ppul.26461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/16/2023] [Accepted: 04/27/2023] [Indexed: 05/06/2023]
Affiliation(s)
- Mohamed Ahmed
- Department of Pediatrics, Indiana University School of Medicine, Division of Pediatric Critical Care Medicine, Indianapolis, Indiana, USA
| | - Maureen Dunn
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perlman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Geoffrey Kurland
- Division of Pulmonary Medicine, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Gregory Burg
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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15
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Ng BH, Low HJ, Nik Abeed NN, Jailaini MFM, Abdul Hamid MF, Ban Yu‐Lin A. The benefit of indwelling pleural catheter with ambulatory pneumothorax device and autologous blood patch pleurodesis in lymphangioleiomyomatosis with persistent air leak. Respirol Case Rep 2023; 11:e01143. [PMID: 37065172 PMCID: PMC10098059 DOI: 10.1002/rcr2.1143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/30/2023] [Indexed: 04/18/2023] Open
Abstract
We report a 35-year-old woman who presented with dyspnoea and chest pain for 1 week. High-resolution computed tomography (HRCT) thorax revealed bilateral pneumothoraces with diffuse lung cysts. Bilateral intercostal chest tubes were inserted, and there was a persistent air leak (PAL) bilaterally. We performed an autologous blood patch pleurodesis (ABPP) for the left PAL. For the right PAL, she underwent a successful right video-assisted thoracic (VATS) surgery, wedge biopsy, and surgical pleurodesis. Histopathology examination confirmed the diagnosis of lymphangioleiomyomatosis (LAM). The left pneumothorax recurred. An indwelling pleural catheter (Rocket® IPC™; Rocket Medical plc; WASHINGTON) was inserted and the patient was discharged after 1 day with an atrium pneumostat (Pneumostat™; Atrium Medical Corporation, Hudson, NH, USA) chest drain valve. The patient was initiated on Sirolimus 2 mg daily. The left PAL resolved at 6 weeks. This case highlights the benefit of IPC with an ambulatory pneumothorax device in a patient with LAM with PAL.
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Affiliation(s)
- Boon Hau Ng
- Pulmonology Unit, Department of Internal Medicine, Faculty of MedicineUniversiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
| | - Hsueh Jing Low
- Department of Anesthesiology & Intensive Care Unit, Faculty of MedicineUniversiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
| | - Nik Nuratiqah Nik Abeed
- Pulmonology Unit, Department of Internal Medicine, Faculty of MedicineUniversiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
| | - Mas Fazlin Mohamad Jailaini
- Pulmonology Unit, Department of Internal Medicine, Faculty of MedicineUniversiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
| | - Mohamed Faisal Abdul Hamid
- Pulmonology Unit, Department of Internal Medicine, Faculty of MedicineUniversiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
| | - Andrea Ban Yu‐Lin
- Pulmonology Unit, Department of Internal Medicine, Faculty of MedicineUniversiti Kebangsaan Malaysia Medical CentreKuala LumpurMalaysia
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16
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Ficial B, Whebell S, Taylor D, Fernández-Garda R, Okiror L, Meadows CIS. Bronchoscopic Endobronchial Valve Therapy for Persistent Air Leaks in COVID-19 Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation. J Clin Med 2023; 12:jcm12041348. [PMID: 36835885 PMCID: PMC9962378 DOI: 10.3390/jcm12041348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/21/2023] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Abstract
COVID-19 acute respiratory distress syndrome (ARDS) can be associated with extensive lung damage, pneumothorax, pneumomediastinum and, in severe cases, persistent air leaks (PALs) via bronchopleural fistulae (BPF). PALs can impede weaning from invasive ventilation or extracorporeal membrane oxygenation (ECMO). We present a series of patients requiring veno-venous ECMO for COVID-19 ARDS who underwent endobronchial valve (EBV) management of PAL. This is a single-centre retrospective observational study. Data were collated from electronic health records. Patients treated with EBV met the following criteria: ECMO for COVID-19 ARDS; the presence of BPF causing PAL; air leak refractory to conventional management preventing ECMO and ventilator weaning. Between March 2020 and March 2022, 10 out of 152 patients requiring ECMO for COVID-19 developed refractory PALs, which were successfully treated with bronchoscopic EBV placement. The mean age was 38.3 years, 60% were male, and half had no prior co-morbidities. The average duration of air leaks prior to EBV deployment was 18 days. EBV placement resulted in the immediate cessation of air leaks in all patients with no peri-procedural complications. Weaning of ECMO, successful ventilator recruitment and removal of pleural drains were subsequently possible. A total of 80% of patients survived to hospital discharge and follow-up. Two patients died from multi-organ failure unrelated to EBV use. This case series presents the feasibility of EBV placement in severe parenchymal lung disease with PAL in patients requiring ECMO for COVID-19 ARDS and its potential to expedite weaning from both ECMO and mechanical ventilation, recovery from respiratory failure and ICU/hospital discharge.
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Affiliation(s)
- Barbara Ficial
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Stephen Whebell
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
- Intensive Care Unit, Townsville University Hospital, 100 Angus Smith Drive, Douglas, QLD 4814, Australia
| | - Daniel Taylor
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Rita Fernández-Garda
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Lawrence Okiror
- Department of Thoracic Surgery, Guy’s and St Thomas’ NHS Foundation Trust, Guy’s Hospital, Great Maze Pond, London SE1 9RT, UK
| | - Christopher I. S. Meadows
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
- Correspondence:
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17
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Cheng HS, Lo YT, Miu FPL, So LKY, Yam LYC. Prevalence, risk factors, and recurrence risk of persistent air leak in patients with secondary spontaneous pneumothorax. Eur Clin Respir J 2023; 10:2168345. [PMID: 36743827 PMCID: PMC9897746 DOI: 10.1080/20018525.2023.2168345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background Persistent air leak (PAL) is common in secondary spontaneous pneumothorax (SSP), with risk factors only been determined for post-pulmonary resection PAL. Information about its risk factors and long-term outcome is, however, necessary to enable selection of treatment modalities for elderly SSP patients with comorbid conditions. Methods A retrospective observational study was performed on chest drain-treated SSP patients from 2009 to 2018. The risk factors, long-term recurrent pneumothorax, and mortality rates of those with and without PAL were evaluated. Results Of 180 non-surgical SSP patients, PAL prevalence for >2 days and >7 days were 81.1% and 43.3%, respectively. Bulla was associated with PAL >7 days (OR: 2.32; P: 0.027) and serum albumin negatively associated (OR: 0.94; P: 0.028). PAL resulted in longer hospitalization in the index episode (P: <0.01). PAL >7 days was associated with a higher pneumothorax recurrence rate in three months (HR: 2.65; P: 0.041), one year (HR: 2.50; P: 0.040) and two-year post-discharge (HR: 2.40; P: 0.029). Patients treated with medical pleurodesis were significantly older (P: <0.01), had higher Charlson Co-morbidity index scores (P: <0.01), and 77.8% of those who had PAL >7 days were considered unfit for surgery. Of these, pneumothorax had not recurred in 69.4% after two years (HR: 0.47; P: 0.044). Conclusion Bulla was positively associated with PAL over seven days in SSP patients while albumin was negatively associated. PAL over seven days increased future recurrent pneumothorax risks, while elderly SSP patients unfit for surgery had acceptable recurrence rates after medical pleurodesis.
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Affiliation(s)
- Hei-Shun Cheng
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China,CONTACT Hei-Shun Cheng Department of Medicine, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong, China
| | - Yi-Tat Lo
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Flora Pui-Ling Miu
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Loletta Kit-Ying So
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Loretta Yin-Chun Yam
- Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
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18
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Train SE, Shafiq M. Old Dog, New Trick: Using Endobronchial Valves to Manage Persistent Air Leak Resulting From Endobronchial Valve Placement. J Bronchology Interv Pulmonol 2023; 30:76-77. [PMID: 35838249 DOI: 10.1097/lbr.0000000000000838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Sarah E Train
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA
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19
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Wu W, Li S, Song X, Wang X, Wang Y, Cai C, Wang J, Li Y, Ma W. Case Report: Differential lung ventilation with jet ventilation via a bronchial blocker for a patient with a large thoracogastric airway fistula after esophagectomy. Front Surg 2022; 9:959527. [DOI: 10.3389/fsurg.2022.959527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/26/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundA thoracogastric airway fistula (TGAF) is a rare and potentially fatal complication of esophagectomy for esophageal and cardia carcinomas. Isolation of the fistula and pulmonary separation is necessary during the surgical repair of a tracheal fistula. However, currently, the reported airway management techniques are not suitable for patients with a large TGAF. This case study presents an alternative technique for performing differential lung ventilation in a patient with a thoracogastric airway fistula.Case presentationA 70-year-old man was diagnosed with a thoracogastric airway fistula situated above the carina after esophagectomy, and a thoracoscope-assisted repair of the fistula and pectoralis major myocutaneous flap transplantation were scheduled. The patient could not tolerate one-lung ventilation and the complex intubating operation due to aspiration pneumonia and the size (3.5 cm × 1.7 cm) of the fistula. We, therefore, performed differential lung ventilation in which an extended 6.5#single-lumen endotracheal tube was inserted into the left main bronchus and a 9Fr bronchial blocker was placed in the right main bronchus by using the video-flexible intubation scope. The right lung was selectively inflated with jet ventilation, while positive pressure ventilation was maintained through the left endotracheal tube. The value of SPO2 remained above 95% throughout the operation.ConclusionFor patients with a large thoracogastric airway fistula, differential lung ventilation of a combination of positive pressure ventilation and jet ventilation is useful. Inserting an extended single-lumen endotracheal tube into the left main bronchus and a bronchial blocker into the right main bronchus could be another way of providing differential ventilation for patients with a large thoracogastric airway fistula.
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20
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Keenan JC, Cho RC, Wong J, Dincer HE. Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience. J Bronchology Interv Pulmonol 2022; 29:269-274. [PMID: 34879034 DOI: 10.1097/lbr.0000000000000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 11/09/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Joseph C Keenan
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, University of Minnesota, Minneapolis, MN
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21
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Baden W, Hofbeck M, Warmann SW, Schaefer JF, Sieverding L. Interventional closure of a bronchopleural fistula in a 2 year old child with detachable coils. BMC Pediatr 2022; 22:250. [PMID: 35513808 PMCID: PMC9074316 DOI: 10.1186/s12887-022-03298-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 04/21/2022] [Indexed: 11/30/2022] Open
Abstract
Background Bronchopleural fistula (BPF) is a severe complication following pneumonia or pulmonary surgery, resulting in persistent air leakage (PAL) and pneumothorax. Surgical options include resection, coverage of the fistula by video-assisted thoracoscopic surgery (VATS), or pleurodesis. Interventional bronchoscopy is preferred in complex cases and involves the use of sclerosants, sealants and occlusive valve devices. Case presentation A 2.5-year-old girl was admitted to our hospital with persistent fever, cough and dyspnoea. Clinical and radiological examination revealed right-sided pneumonia and pleural effusion. The child was started on antibiotics, and the effusion was drained by pleural drainage. Following removal of the chest tube, the child developed tension pneumothorax. Despite insertion of a new drain, the air leak persisted. Thoracoscopic debridement with placement of another new drain was performed after 4 weeks, without abolishment of the air leak. Bronchoscopy with bronchography revealed a BPF in right lung segment 3 (right upper-lobe anterior bronchus). We opted for an interventional approach that was performed under general anaesthesia during repeat bronchoscopy. Following bronchographic visualisation of the fistula, a 2.7 French microcatheter was placed in right lung segment 3 (upper lobe), allowing occlusion of the fistula by successive implantation of 4 detachable high-density packing volume coils, which were placed into the fistula. Subsequent bronchography revealed no evidence of residual leakage, and the chest tube was removed 2 days later. The chest X-ray findings normalized, and follow-up over 4 years was uneventful. Conclusions Bronchoscopic superselective occlusion of BPF using detachable high-density packing large-volume coils was a successful minimally invasive therapeutic intervention performed with minimal trauma in this child and has not been reported thus far. In our small patient, the short interventional time, localized intervention and minimal damage in the lung seemed superior to the corresponding outcomes of surgical lobectomy or pleurodesis in a young growing lung, enabling normal development of the surrounding tissue. Follow-up over 4 years did not show any side effects and was uneventful, with normal lung-function test results to date. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03298-y.
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Affiliation(s)
- Winfried Baden
- Department Paediatrics 2, Pulmonology, Cardiology, Intensive Care, Children's Hospital, University of Tuebingen, Hoppe-Seyler-Strasse 1, 72076, Tuebingen, Germany.
| | - Michael Hofbeck
- Department Paediatrics 2, Pulmonology, Cardiology, Intensive Care, Children's Hospital, University of Tuebingen, Hoppe-Seyler-Strasse 1, 72076, Tuebingen, Germany
| | - Steven W Warmann
- Department Paediatric Surgery and Paediatric Urology, Children's Hospital, University of Tuebingen, Tuebingen, Germany
| | - Juergen F Schaefer
- Department Radiology, Division of Paediatric Radiology, University Hospital, Tuebingen, Germany
| | - Ludger Sieverding
- Department Paediatrics 2, Pulmonology, Cardiology, Intensive Care, Children's Hospital, University of Tuebingen, Hoppe-Seyler-Strasse 1, 72076, Tuebingen, Germany
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22
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Aliaga F, Grosu HB, Vial MR. Overview of Bronchopleural Fistula Management, with a Focus on Bronchoscopic Treatment. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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23
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Schütz K, Happel CM, Keil O, Dingemann J, Carlens J, Wetzke M, Müller C, Köditz H, Griese M, Reiter K, Schweiger-Kabesch A, Backendorf A, Scharff A, Bertram H, Schwerk N. Interventional Bronchus Occlusion Using Amplatzer Devices - A Promising Treatment Option for Children with Persistent Air Leak. KLINISCHE PADIATRIE 2022; 234:293-300. [PMID: 34979579 DOI: 10.1055/a-1697-5624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Persistent air leak (PAL) is a severe complication of secondary spontaneous pneumothorax (SSP). Surgical interventions are usually successful when medical treatment fails, but can be associated with significant complications and loss of potentially recoverable lung parenchyma. METHODS Retrospective analysis of efficacy and safety of interventional bronchus occlusions (IBO) using Amplatzer devices (ADs) in children with PAL secondary to SSP. RESULTS Six patients (four males, 4-15 years of age) underwent IBO using ADs as treatment for PAL. Necrotizing pneumonia (NP) was the most common cause (n=4) of PAL. Three patients were previously healthy and three suffered from chronic lung disease. All patients required at least two chest tubes prior to the intervention for a duration of 15-43 days and all required oxygen or higher level of ventilatory support. In three cases, previous surgical interventions had been performed without success. All children improved after endobronchial intervention and we observed no associated complications. All chest tubes were removed within 5-25 days post IBO. In patients with PAL related to NP (n=4), occluders were removed bronchoscopically without re-occurrence of pneumothorax after a mean of 70 days (IQR: 46.5-94). CONCLUSION IBO using ADs is a safe and valuable treatment option in children with PAL independent of disease severity and underlying cause. A major advantage of this procedure is its less invasiveness compared to surgery and the parenchyma- preserving approach.
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Affiliation(s)
- Katharina Schütz
- Department of Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland.,Excellence Cluster RESIST - Resolving Infection Susceptibility, Hannover Medical School, Hannover, Deutschland
| | - Christoph M Happel
- Pediatric Cardiology and Pediatric Intensive Care, Hanover Medical Specialists, Hanover, Deutschland
| | - Oliver Keil
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Deutschland
| | - Jens Dingemann
- Department of Paediatric Surgery, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland
| | - Julia Carlens
- Department of Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland
| | - Martin Wetzke
- Department of Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland
| | - Carsten Müller
- Department of Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland
| | - Harald Köditz
- Department of Paediatric Cardiology and Intensive Care Medicine, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland
| | - Matthias Griese
- Department of Paediatric Pneumology, Dr. von Haunersches Kinderspital, German Center for Lung Research, University of Munich, Munich, Deutschland
| | - Karl Reiter
- Department of Paediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO) at the Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Deutschland
| | - Andrea Schweiger-Kabesch
- Department of Paediatric Pneumology and Allergy, University Children's Hospital Regensburg (KUNO) at the Hospital St. Hedwig of the Order of St. John, University of Regensburg, Regensburg, Deutschland
| | - Alexander Backendorf
- Department of Neonatology and Paediatric Intensive Care, Vestische Childrenhospital Datteln, University of Witten/Herdecke, Datteln, Deutschland
| | - AnnaZychlinsky Scharff
- Department of Paediatric Haematology and Oncology, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland
| | - Harald Bertram
- Department of Paediatric Pneumology, Dr. von Haunersches Kinderspital, German Center for Lung Research, University of Munich, Munich, Deutschland
| | - Nicolaus Schwerk
- Department of Paediatric Pulmonology, Allergology and Neonatology, Hannover Medical School Centre for Paediatrics and Adolescent Medicine, Hannover, Deutschland.,BREATH (Biomedical Research in End-stage and obstructive Lung Disease Hannover), German Center for Lung Research (DZL), Hannover, Deutschland
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Ramadurai D, DiBardino DM, Hong G. Endobronchial valve placement in secondary pneumothorax related to allergic bronchopulmonary aspergillosis. Respir Med Case Rep 2021; 34:101554. [PMID: 34820259 PMCID: PMC8602042 DOI: 10.1016/j.rmcr.2021.101554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 11/06/2022] Open
Abstract
Secondary pneumothorax is a rare but serious complication of allergic bronchopulmonary aspergillosis (ABPA) and bronchiectasis [1,2]. Persistent air leak (PAL) after secondary pneumothorax is an ongoing abnormal communication between bronchi or alveoli and the pleural space, despite drainage. Ongoing PAL for 5 days after initial chest tube insertion necessitates prolonged ambulatory drainage or aggressive management with video-assisted thoracoscopic surgery (VATS) or pleurodesis [3,4]. There are no randomized trials examining the efficacy of endobronchial valves (EBVs) for PAL with underlying inflammatory pulmonary disease. We describe the successful use of an EBV for PAL in a man with ABPA on high dose steroids, with a large bronchopleural fistula (BPF).
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Affiliation(s)
- Deepa Ramadurai
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David M DiBardino
- Section of Interventional Pulmonology and Thoracic Oncology, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gina Hong
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
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25
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Abstract
Pneumothorax is a common medical condition encountered in a wide variety of clinical presentations, ranging from asymptomatic to life threatening. When symptomatic, it is important to remove air from the pleural space and provide re-expansion of the lung. Additionally, patients who experience a spontaneous pneumothorax are at high risk for recurrence, so treatment goals also include recurrence prevention. Several recent studies have evaluated less invasive management strategies for pneumothorax, including conservative or outpatient management. Future studies may help to identify who is greatest at risk for recurrence and direct earlier definitive management strategies, including thoracoscopic surgery, to those patients.
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26
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Bai Y, Li Y, Chi J, Guo S. Endobronchial closure of the bronchopleural fistula with the ventricular septal defect occluder: a case series. BMC Pulm Med 2021; 21:313. [PMID: 34620149 PMCID: PMC8496023 DOI: 10.1186/s12890-021-01676-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/20/2021] [Indexed: 11/10/2022] Open
Abstract
Objectives The ventricular septal defect (VSD) occluder has been reported to be a novel method for the closure of bronchopleural fistula (BPF). Our study was to confirm the use of VSD occluder in treating BPF after pneumonectomy or lobectomy. Methods
We performed a single-center, retrospective study of 10 consecutive patients (8 men and 2 women aged 29–70 years) with postoperative BPF receiving the VSD occluder treatment. We used the HeartR™ Membranous VSD occluder (Lifetech Scientific Co., Shenzhen, China) for the closure of BPF through flexible bronchoscopy under general anesthesia. Demographic characteristics, BPF characteristics, and clinical outcomes were collected from patients’ files using the standardized data abstraction forms. Results The underlying diseases were lung cancer in 6 patients, pulmonary tuberculosis in 3, and bronchiectasis in 1. Right-sided BPFs occurred in 6 patients, and left-sided BPFs occurred in 4. Five patients were underweight with a body mass index < 18.5 kg/m2. The VSD was placed in all 10 patients with a 100% technical success rate and a 70% complete closure rate during follow-up with no complications, on a median follow-up period of 115 days (range 46–975 days). In 1 patient, the VSD occluder was reinstalled with complete closure; in 1 and 2 patients with underweight and chronic empyema, the VSD occluders partially and completely failed with good physical tolerance, respectively. Conclusions Our study demonstrated the bronchoscopic closure of BPF after lung resection using the VSD occluder is an off-label but safe and effective method. We prefer to stabilize the BPF by eradicating the underlying diseases and providing nutritional support to those receiving VSD occluder closure treatment.
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Affiliation(s)
- Yang Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, PR China
| | - Yishi Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, PR China
| | - Jing Chi
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, PR China
| | - Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, No.1 Youyi Road, Yuzhong District, Chongqing, 400016, PR China.
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27
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Kida H, Muraoka H, Morikawa K, Inoue T, Mineshita M. Pleurodesis After Bronchial Occlusion for Inoperable Secondary Spontaneous Pneumothorax. J Bronchology Interv Pulmonol 2021; 28:290-295. [PMID: 34191760 DOI: 10.1097/lbr.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 05/25/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In many cases of secondary spontaneous pneumothorax (SSP), surgery is not feasible. Furthermore, in cases with a collapsed lung or numerous air leaks, pleurodesis is ineffective, and treatment options are severely limited. For these cases, bronchial occlusion might be the only effective treatment, despite the low success rate. If, however, bronchial occlusion can expand the lung and reduce air leakage, it can positively amplify later effects on pleurodesis, resulting in a powerful treatment. We reviewed the clinical data of patients who underwent bronchial occlusion with endobronchial Watanabe spigot (BO-EWS) and pleurodesis to investigate the usefulness of bronchial occlusion therapy in inoperable SSP patients. MATERIALS AND METHODS This single-center, retrospective study reviewed 36 cases of inoperable SSP patients who underwent pleurodesis after BO-EWS from April 2007 to October 2018. Twenty cases were allocated to the air leak analysis group, and 16 cases were included in the pneumothorax volume analysis group. The Robert David Cerfolio classification and the Collins method were used to evaluate air leak and pneumothorax volume, respectively. RESULTS Pneumothorax volumes decreased significantly after BO-EWS from 29.1%±17.3% to 12.1%±8.8%, while the air leak score decreased from 2.9±1.4 to 1.2±1.0. The success rate for chest tube removals in cases that underwent pleurodesis after BO-EWS was 85.0% (17/20). CONCLUSIONS This study demonstrated the synergistic effectiveness of BO-EWS and the usefulness of pleurodesis treatment in inoperable SSP patients with lung collapse or numerous air leaks. We believe that this treatment will benefit patients with inoperable SSP which, until now, has had few treatment options.
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Affiliation(s)
- Hirotaka Kida
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| | - Hiromi Muraoka
- Department of Internal Medicine, Division of Respiratory Medicine, St. Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Kei Morikawa
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| | - Takeo Inoue
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
| | - Masamichi Mineshita
- Department of Internal Medicine, Division of Respiratory Diseases, St. Marianna University School of Medicine, Kawasaki
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28
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Donatelli P, Trenatacosti F, Pellegrino MR, Tonelli R, Bruzzi G, Andreani A, Cappiello GF, Andrisani D, Gozzi F, Mussini C, Busani S, Cavaliere GV, Girardis M, Bertellini E, Clini E, Marchioni A. Endobronchial valve positioning for alveolar-pleural fistula following ICU management complicating COVID-19 pneumonia. BMC Pulm Med 2021; 21:307. [PMID: 34579700 PMCID: PMC8475464 DOI: 10.1186/s12890-021-01653-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 09/01/2021] [Indexed: 12/12/2022] Open
Abstract
Background The main clinical consequences of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection are pneumonia and respiratory failure even requiring mechanical ventilation. In this context, the lung parenchyma is highly prone to ventilator-related injury, with pneumothorax and persistent air leak as the most serious adverse events. So far, endobronchial valve (EBV) positioning has proved efficacious in treating air leaks with a high success rate. Case presentation We report, for the first time, two cases of patients affected by SARS-CoV-2-related pneumonia complicated with bacterial super-infection, experiencing pneumothorax and persistent air leaks after invasive mechanical ventilation. Despite the severity of respiratory failure both patients underwent rigid interventional bronchoscopy and were successfully treated through EBV positioning. Conclusions Persistent air leaks may result from lung tissue damage due to a complex interaction between inflammation and ventilator-related injury (VILI), especially in the advanced stages of ARDS. EBV positioning seems to be a feasible and effective minimally invasive therapeutic option for treating this subset of patients.
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Affiliation(s)
- Pierluigi Donatelli
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Fabiana Trenatacosti
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Maria Rosaria Pellegrino
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Roberto Tonelli
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy. .,Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Via Università 4, 41121, Modena, Italy. .,Laboratory of Experimental Pneumology, Modena, Italy. .,Respiratory Diseases Unit and Center for Rare Lung Disease, Department of Surgical and Medical Sciences, University Hospital of Modena, Via del Pozzo, 71, 41125, Modena, Italy.
| | - Giulia Bruzzi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Andreani
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Gaia Francesca Cappiello
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Dario Andrisani
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Via Università 4, 41121, Modena, Italy
| | - Filippo Gozzi
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Via Università 4, 41121, Modena, Italy
| | - Cristina Mussini
- University Hospital of Modena, Infectious Diseases Unit, University of Modena Reggio Emilia, Modena, Italy
| | - Stefano Busani
- University Hospital of Modena, Anesthesiology Unit, University of Modena Reggio Emilia, Modena, Italy
| | - Gilda Valentina Cavaliere
- University Hospital of Modena, Anesthesiology Unit, University of Modena Reggio Emilia, Modena, Italy
| | - Massimo Girardis
- University Hospital of Modena, Anesthesiology Unit, University of Modena Reggio Emilia, Modena, Italy
| | - Elisabetta Bertellini
- University Hospital of Modena, Anesthesiology Unit, University of Modena Reggio Emilia, Modena, Italy
| | - Enrico Clini
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Alessandro Marchioni
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
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Green DB, Groner LK, Lee JJ, Shin J, Broncano J, Vargas D, Castro M, Shostak E. Overview of Interventional Pulmonology for Radiologists. Radiographics 2021; 41:1916-1935. [PMID: 34534017 DOI: 10.1148/rg.2021210046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Interventional pulmonology is a growing field specializing in minimally invasive procedures of the mediastinum, lungs, airways, and pleura. These procedures have both diagnostic and therapeutic indications and are performed for benign and malignant diseases. Endobronchial US has been combined with transbronchial needle aspiration to extend tissue sampling beyond the airways and into the lungs and mediastinum. Recent innovations extending the peripheral access of bronchoscopy include electromagnetic navigational bronchoscopy and thinner bronchoscopes. An important indication for therapeutic bronchoscopy is the relief of central airway obstruction, which may be severe and life threatening. Techniques for restoring patency of the central airways include mechanical debulking and multiple modalities for ablation, stent placement, and balloon bronchoplasty. Bronchoscopic lung volume reduction improves quality of life in certain patients with severe emphysema and is an important less invasive alternative to lung volume reduction surgery. Bronchial thermoplasty is likewise a nonpharmacologic treatment in patients with severe uncontrolled asthma. Many of these procedures have unique selection criteria that require precise evaluations at preprocedure imaging. Postprocedure imaging is also essential in determining outcome success and the presence of complications. Radiologists should be familiar with these procedures as well as the relevant imaging features in both planning and later surveillance. Evolving techniques that may become more widely available in the near future include robotic-assisted bronchoscopy, bronchoscopic transparenchymal nodule access, transbronchial cryobiopsy, ablation of early-stage cancers, and endobronchial intratumoral chemotherapy. An invited commentary by Wayne et al is available online. ©RSNA, 2021.
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Affiliation(s)
- Daniel B Green
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Lauren K Groner
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Jared J Lee
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - James Shin
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Jordi Broncano
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Daniel Vargas
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Mario Castro
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
| | - Eugene Shostak
- From the Departments of Radiology (D.B.G., L.K.G., J.S.) and Cardiothoracic Surgery (E.S.), Weill Cornell Medicine, 525 E 68th St, Box 141, New York, NY 10065; Departments of Medicine (J.J.L.) and Radiology (D.V.), University of Colorado, Aurora, Colo; Department of Radiology, Hospital San Juan de Dios, Córdoba, Spain (J.B.); and Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, Kan (M.C.)
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Thachuthara-George J. Pneumothorax in patients with respiratory failure in ICU. J Thorac Dis 2021; 13:5195-5204. [PMID: 34527359 PMCID: PMC8411185 DOI: 10.21037/jtd-19-3752] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/24/2021] [Indexed: 11/15/2022]
Abstract
Pneumothorax is not an uncommon occurrence in ICU patients. Barotrauma and iatrogenesis remain the most common causes for pneumothorax in critically ill patients. Patients with underlying lung disease are more prone to develop pneumothorax, especially if they require positive pressure ventilation. A timely diagnosis of pneumothorax is critical as it may evolve into tension physiology. Most occurrences of pneumothoraces are readily diagnosed with a chest X-ray. Tension pneumothorax is a medical emergency, and managed with immediate needle decompression followed by tube thoracostomy. A computed tomography (CT) scan of the chest remains the gold standard for diagnosis; however, getting a CT scan of the chest in a critically ill patient can be challenging. The use of thoracic ultrasound has been emerging and is proven to be superior to chest X-ray in making a diagnosis. The possibility of occult pneumothorax in patients with thoracoabdominal blunt trauma should be kept in mind. Patients with pneumothorax in the ICU should be managed with a tube thoracostomy if they are symptomatic or on mechanical ventilation. The current guidelines recommend a small-bore chest tube as the first line management of pneumothorax. In patients with persistent air leak or whose lungs do not re-expand, a thoracic surgery consultation is recommended. In non-surgical candidates, bronchoscopic interventions or autologous blood patch are other options.
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Affiliation(s)
- Joseph Thachuthara-George
- Interventional Pulmonary Program, Division of Pulmonary, Allergy, and Critical Care Medicine, UAB, The University of Alabama at Birmingham, Birmingham, AL, USA
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31
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Kurman JS. Persistent air leak management in critically ill patients. J Thorac Dis 2021; 13:5223-5231. [PMID: 34527361 PMCID: PMC8411173 DOI: 10.21037/jtd-2021-32] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/11/2021] [Indexed: 12/13/2022]
Abstract
Persistent air leak (PAL) is a challenging clinical entity, particularly in the setting of critical illness. It is a significant cause of morbidity, health care expenditure, and resource utilization. Data on its prevalence in the critically ill patient population are limited. Unique patient factors often necessitate an individualized approach. Guidelines on this subject are antiquated and do not specially address patients on mechanical ventilation. Critically ill patients may not be able to tolerate surgical intervention. Treatment in this population relies upon lung protective ventilation, various anecdotal modalities, chemical pleurodesis, autologous blood patching, and bronchoscopic insertion of endobronchial valves. Ventilation strategies center on rapid weaning and reduction of airway pressures. Anecdotal methods include implantable devices and chemical agents. Data on these modalities are limited to case reports. None have United States Food and Drug Administration (FDA) approval. The Spiration Valve System is FDA approved as a Humanitarian Device Exemption. Data on endobronchial valves are based on large case series, and only one small case series has focused exclusively on critically ill patients. The majority of valves in critically ill mechanically ventilated patients are used for non-FDA approved indications. Updated guidelines are desperately needed to ensure a standardized approach to this common clinical situation.
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Affiliation(s)
- Jonathan S Kurman
- Division of Pulmonary & Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA
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32
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Guo S, Bai Y, Li Y, Chen T. A Large Central Bronchopleural Fistula Closed by Bronchoscopic Administration of Recombinant Bovine Basic Fibroblast Growth Factor: A Case Report. Respiration 2021; 100:1000-1004. [PMID: 34515226 DOI: 10.1159/000514717] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/14/2021] [Indexed: 11/19/2022] Open
Abstract
A large central bronchopleural fistula (BPF) surrounded by mediastinal tissue was successfully closed by local administration of recombinant bovine basic fibroblast growth factor (rbFGF) using the bronchoscope. No complications were observed during and after this bronchoscopic treatment. This is the first report of the bronchoscopic treatment of a large central BPF by the local spray of rbFGF. The bronchoscopic treatment with rbFGF is a potentially cost-effective method for central BPF surrounded by mediastinal tissue.
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Affiliation(s)
- Shuliang Guo
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yishi Li
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tao Chen
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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33
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Karampinis I, Galata C, Arani A, Grilli M, Hetjens S, Shackcloth M, Buderi S, Stamenovic D, Roessner ED. Autologous blood pleurodesis for the treatment of postoperative air leaks. A systematic review and meta-analysis. Thorac Cancer 2021; 12:2648-2654. [PMID: 34477307 PMCID: PMC8520794 DOI: 10.1111/1759-7714.14138] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/18/2021] [Accepted: 08/19/2021] [Indexed: 01/21/2023] Open
Abstract
Background Postoperative air leaks are a common complication after lung surgery. They are associated with prolonged hospital stay, increased postoperative pain and treatment costs. The treatment of prolonged air leaks remains controversial. Several treatments have been proposed including different types of sealants, chemical pleurodesis, or early surgical intervention. The aim of this review was to analyze the impact of autologous blood pleurodesis in a systematic way. Methods A systematic review of the literature was conducted until July 2020. Studies with more than five adult patients undergoing lung resections were included. Studies in patients receiving blood pleurodesis for pneumothorax were excluded. The search strategy included proper combinations of the MeSH terms “air leak”, “blood transfusion” and “lung surgery”. Results Ten studies with a total of 198 patients were included in the analysis. The pooled success rate for sealing the air leak within 48 h of the blood pleurodesis was 83.7% (95% CI: 75.7; 90.3). The pooled incidence of the post‐interventional empyema was 1.5%, with a pooled incidence of post‐interventional fever of 8.6%. Conclusions Current evidence supports the idea that autologous blood pleurodesis leads to a faster healing of postoperative air leaks than conservative treatment. The complication rate is very low. Formal recommendations on how to perform the procedure are not possible with the current evidence. A randomized controlled trial in the modern era is necessary to confirm the benefits.
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Affiliation(s)
- Ioannis Karampinis
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany.,Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Christian Galata
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Alireza Arani
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Maurizio Grilli
- Department of Library and Information Sciences, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Svetlana Hetjens
- Medical Faculty Mannheim, Institute of Medical Statistic and Biomathematics, University Medical Center Mannheim, Heidelberg University, Mannheim, Germany
| | - Michael Shackcloth
- Division of Thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Silviu Buderi
- Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Davor Stamenovic
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Eric D Roessner
- Division of Thoracic Surgery, Academic Thoracic Center Mainz, University Medical Center Mainz, Johannes Gutenberg University Mainz, Mainz, Germany
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Kreso A, Mathisen DJ. Management of Air Leaks and Residual Spaces Following Lung Resection. Thorac Surg Clin 2021; 31:265-271. [PMID: 34304834 DOI: 10.1016/j.thorsurg.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Air leaks and residual airspaces following lung resection are common problems in thoracic surgery. Prolonged air leaks frequently necessitate extended hospitalization. This is true whether the surgery was done in an open fashion or with video-/robot-assisted thoracic surgery. In this review, the authors present common risk factors that predispose to prolonged air leaks and discuss the management options for air leaks by focusing on intraoperative maneuvers, postoperative considerations, and options for difficult-to-manage air leaks and spaces. They also discuss options to prevent such spaces and present management approaches to take care of patients with these challenging problems.
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Affiliation(s)
- Antonia Kreso
- Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street Founders 7, Boston, MA 02114, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street Founders 7, Boston, MA 02114, USA.
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35
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Koster TD, Klooster K, Ten Hacken NHT, van Dijk M, Slebos DJ. Endobronchial valve therapy for severe emphysema: an overview of valve-related complications and its management. Expert Rev Respir Med 2020; 14:1235-1247. [PMID: 32842819 DOI: 10.1080/17476348.2020.1813571] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Bronchoscopic lung volume reduction treatment with one-way valves is an effective guideline treatment option for patients with severe emphysema. However, important challenges and adverse reactions may occur after treatment. AREAS COVERED This review summarizes the complications after endobronchial and intrabronchial valve treatment that have been described by the currently published randomized controlled trials and other relevant papers regarding the complications and its management. In case there was no relevant literature regarding these subjects, recommendations are based on expert opinion. Complications include pneumothorax, post-obstruction pneumonia and hemoptysis. Also, the treatment may not be effective due to the presence of collateral ventilation or misplaced valves. Furthermore, an initial beneficial effect may vanish due to granulation tissue formation, valve dysfunction or valve migration. Careful follow-up after treatment with valves is important. Evaluation with a CT-scan and/or bronchoscopy is needed if there is no improvement after treatment, loss of benefit, or occurrence of important adverse events during follow-up. EXPERT OPINION Treating severe emphysema patients with one-way valves requires continuous dedication and expertise, especially to achieve an optimal outcome and elegantly deal with the various complications after treatment.
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Affiliation(s)
- T David Koster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Karin Klooster
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Nick H T Ten Hacken
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Marlies van Dijk
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen , Groningen, The Netherlands.,Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen , Groningen, The Netherlands
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Trends in Intrabronchial Valve Implantation in Patients with Persistent Air Leak: Analysis of a Nationwide Database over a 10-Year Period. Ann Am Thorac Soc 2020; 17:1642-1645. [PMID: 32783784 DOI: 10.1513/annalsats.201909-695rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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37
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Clark JM, Cooke DT, Brown LM. Management of Complications After Lung Resection: Prolonged Air Leak and Bronchopleural Fistula. Thorac Surg Clin 2020; 30:347-358. [PMID: 32593367 PMCID: PMC10846534 DOI: 10.1016/j.thorsurg.2020.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Prolonged air leak or alveolar-pleural fistula is common after lung resection and can usually be managed with continued pleural drainage until resolution. Further management options include blood patch administration, chemical pleurodesis, and 1-way endobronchial valve placement. Bronchopleural fistula is rare but is associated with high mortality, often caused by development of concomitant empyema. Bronchopleural fistula should be confirmed with bronchoscopy, which may allow bronchoscopic intervention; however, transthoracic stump revision or window thoracostomy may be required.
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Affiliation(s)
- James M Clark
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, 2335 Stockton Boulevard, 6th Floor North Addition Office Building, Sacramento, CA 95817, USA. https://twitter.com/JamesClarkMD
| | - David T Cooke
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, 2335 Stockton Boulevard, 6th Floor North Addition Office Building, Sacramento, CA 95817, USA. https://twitter.com/DavidCookeMD
| | - Lisa M Brown
- Section of General Thoracic Surgery, Department of Surgery, University of California, Davis Health, 2335 Stockton Boulevard, 6th Floor North Addition Office Building, Sacramento, CA 95817, USA.
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38
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Bongers KS, De Cardenas J. Endobronchial valve treatment of persistent alveolopleural fistulae in a patient with cystic fibrosis and empyema. J Cyst Fibros 2020; 19:e36-e38. [PMID: 32312675 DOI: 10.1016/j.jcf.2020.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/21/2020] [Accepted: 03/24/2020] [Indexed: 11/18/2022]
Abstract
Persistent air leak (PAL) is a common problem after secondary pneumothorax due to cystic fibrosis (CF). These leaks, caused by either bronchopleural or alveolopleural fistula, are associated with higher morbidity and mortality [1]. Air leaks are traditionally treated with chronic chest tube drainage, chemical pleurodesis, or autologous blood patching in non-surgical candidates [1]. However, these strategies can increase infectious risk or pleural scarring, which are associated with poorer lung transplant surgical outcomes. Endobronchial valve (EBV) placement, while FDA-approved for use in both some surgical PALs and bronchoscopic volume reduction therapy, is one alternative option, but it could theoretically increase the risk of infection, especially in CF patients. Here, we report the case of a CF patient under evaluation for lung transplant who received EBVs for PAL after bilateral secondary spontaneous pneumothoraces.
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Affiliation(s)
- Kale S Bongers
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - Jose De Cardenas
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Wen Y, Liang CN, Zhou Y, Ma HF, Hou G. Endobronchial Valves for the Treatment of Bronchopleural Fistula and Pneumothorax Caused by Pulmonary Cryptococcosis in an AIDS Patient. Front Med (Lausanne) 2020; 7:51. [PMID: 32133366 PMCID: PMC7040219 DOI: 10.3389/fmed.2020.00051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 02/03/2020] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Ying Wen
- Department of Infectious Diseases, First Hospital of China Medical University, Shenyang, China
| | - Chao-Nan Liang
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
| | - Ying Zhou
- Department of Infectious Diseases, First Hospital of China Medical University, Shenyang, China
| | - Hai-Feng Ma
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
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Abu-Hijleh M, Styrvoky K, Anand V, Woll F, Yarmus L, Machuzak MS, Nader DA, Mullett TW, Hogarth DK, Toth JW, Acash G, Casal RF, Hazelrigg S, Wood DE. Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery. Lung 2019; 197:627-633. [PMID: 31463549 DOI: 10.1007/s00408-019-00268-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/21/2019] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Muhanned Abu-Hijleh
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, POB Building II, Dallas, TX, 75390, USA.
| | - Kim Styrvoky
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vikram Anand
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Fernando Woll
- Division of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Section of Interventional Pulmonology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Michael S Machuzak
- Department of Pulmonary, Allergy, Critical Care Medicine and Transplant Center, Interventional Pulmonology, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Nader
- Department of Medicine, Pulmonary and Critical Care Medicine, Interventional Pulmonology, Cancer Treatment Centers of America, Tulsa, OK, USA
| | - Timothy W Mullett
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, KY, USA
| | - D Kyle Hogarth
- Section of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Chicago Medical Center, Chicago, IL, USA
| | - Jennifer W Toth
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ghazwan Acash
- Department of Pulmonary and Critical Care Medicine, Interventional Pulmonology, Lahey Hospital and Medical Center, Tufts University School of Medicine, Burlington, MA, USA
| | - Roberto F Casal
- Department of Pulmonary Medicine, Interventional Pulmonology, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
| | - Stephen Hazelrigg
- Department of Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Douglas E Wood
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington, Seattle, WA, USA
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Bronstein ME, Koo DC, Weigel TL. Management of air leaks post-surgical lung resection. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:361. [PMID: 31516907 DOI: 10.21037/atm.2019.04.30] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
| | | | - Tracey L Weigel
- Division of Thoracic Surgery, Westchester Medical Center, Valhalla, NY, USA
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Zhang HT, Xie YH, Gu X, Li WP, Zeng YM, Li SY, Liu ZG, Wang HW, Bai C, Jin FG. Management of Persistent Air Leaks Using Endobronchial Autologous Blood Patch and Spigot Occlusion: A Multicentre Randomized Controlled Trial in China. Respiration 2019; 97:436-443. [PMID: 30904909 DOI: 10.1159/000495298] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 11/09/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Optimal management of persistent air leaks (PALs) in patients with secondary spontaneous pneumothorax (SSP) remains controversial. OBJECTIVE To evaluate the efficacy and safety of endobronchial autologous blood plus thrombin patch (ABP) and bronchial occlusion using silicone spigots (BOS) in patients with SSP accompanied by alveolar-pleural fistula (APF) and PALs. METHODS This prospective multicentre randomized controlled trial compared chest tube-attached water-seal drainage (CTD), ABP, and BOS that were performed between February 2015 and June 2017 in one of six tertiary care hospitals in China. Patients diagnosed with APF experiencing PALs (despite 7 days of CTD) and inoperable patients were included. Outcome measures included success rate of pneumothorax resolution at the end of the observation period (further 14 days), duration of air leak stop, lung expansion, hospital stay, and complications. RESULTS In total, 150 subjects were analysed in three groups (CTD, ABP, BOS) of 50 each. At 14 days, 60, 82, and 84% of CTD, ABP, and BOS subjects, respectively, experienced full resolution of pneumothorax (p = 0.008). All duration outcome measures were significantly better in the ABP and BOS groups than in the CTD group (p < 0.016 for all). The incidence of adverse events, including chest pain, cough, and fever, was not significantly different. All subjects in the ABP and BOS groups experienced temporary haemoptysis. Spigot displacement occurred in 8% of BOS subjects. CONCLUSION ABP and BOS resulted in clinically meaningful outcomes, including higher success rate, duration of air leak stop, lung expansion, and hospital stay, with an acceptable safety profile.
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Affiliation(s)
- Hai-Tao Zhang
- Department of Respiration, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Yong-Hong Xie
- Department of Respiration, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Xing Gu
- Department of Respiration, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Wang-Ping Li
- Department of Respiration, Tangdu Hospital, Air Force Military Medical University, Xi'an, China
| | - Yi-Ming Zeng
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Shi-Yue Li
- Department of Respiratory, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhi-Guang Liu
- Department of Respiratory Medicine, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Hong-Wu Wang
- Department of Medical Oncology, Meitan General Hospital, Beijing, China
| | - Chong Bai
- Department of Respiratory Medicine, Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Fa-Guang Jin
- Department of Respiration, Tangdu Hospital, Air Force Military Medical University, Xi'an, China,
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43
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Stoller JK. Giants in Chest Medicine: Professor Atul C. Mehta, MBBS, FCCP. Chest 2019; 155:254-257. [DOI: 10.1016/j.chest.2018.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 10/16/2018] [Indexed: 10/27/2022] Open
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Mayor JM, Lazarus DR, Casal RF, Omer S, Preventza O, Simpson K, Jimenez E, Cornwell LD. Air Leak Management Program With Digital Drainage Reduces Length of Stay After Lobectomy. Ann Thorac Surg 2018; 106:1647-1653. [DOI: 10.1016/j.athoracsur.2018.07.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 06/13/2018] [Accepted: 07/09/2018] [Indexed: 10/28/2022]
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Fiorelli A, D'Andrilli A, Cascone R, Occhiati L, Anile M, Diso D, Cassiano F, Poggi C, Ibrahim M, Cusumano G, Terminella A, Failla G, La Sala A, Bezzi M, Innocenti M, Torricelli E, Venuta F, Rendina EA, Vicidomini G, Santini M, Andreetti C. Unidirectional endobronchial valves for management of persistent air-leaks: results of a multicenter study. J Thorac Dis 2018; 10:6158-6167. [PMID: 30622787 DOI: 10.21037/jtd.2018.10.61] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio D'Andrilli
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Roberto Cascone
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Luisa Occhiati
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Anile
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Daniele Diso
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Francesco Cassiano
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Camilla Poggi
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Mohsen Ibrahim
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Giacomo Cusumano
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Alberto Terminella
- Thoracic Surgery Unit, Policlinico Vittorio Emanuele Hospital, Catania, Italy
| | - Giuseppe Failla
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Alba La Sala
- Interventional Pneumology Unit, Ospedale Civico Palermo, Palermo, Italy
| | - Michela Bezzi
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | | | - Elena Torricelli
- Interventional Pneumology Unit, Policlinico Firenze, Florence, Italy
| | - Federico Venuta
- Thoracic Surgery Unit, Università La Sapienza, Policlinico Hospital, Rome, Italy
| | - Erino Angelo Rendina
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
| | - Giovanni Vicidomini
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Santini
- Thoracic Surgery Unit, Università della Campania "Luigi Vanvitelli", Naples, Italy
| | - Claudio Andreetti
- Thoracic Surgery Unit, Università La Sapienza, Sant'Andrea Hospital, Rome, Italy
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Poggi C, Mantovani S, Pecoraro Y, Carillo C, Bassi M, D'Andrilli A, Anile M, Rendina EA, Venuta F, Diso D. Bronchoscopic treatment of emphysema: an update. J Thorac Dis 2018; 10:6274-6284. [PMID: 30622803 DOI: 10.21037/jtd.2018.10.43] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is the major causes of disability and mortality. The efficacy of maximal medical treatment, although effective at the early stages of the disease, becomes limited when extensive alveolar destruction is the main cause of respiratory failure. At this stage of the disease more aggressive options, when feasible, should be considered. Lung transplantation and lung volume reduction surgery (LVRS) are currently available for a selected group of patients. Endoscopic alternatives to LVRS have progressively gained acceptance and are currently employed in patients with COPD. They promote lung deflation searching the same outcome as LVRS in terms of respiratory mechanics, ameliorating the distressing symptom of chronic dyspnea by decreasing the physiological dead space.
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Affiliation(s)
- Camilla Poggi
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Sara Mantovani
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Ylenia Pecoraro
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Carolina Carillo
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Massimiliano Bassi
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Antonio D'Andrilli
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Marco Anile
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Erino A Rendina
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Federico Venuta
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
| | - Daniele Diso
- Department of Thoracic Surgery, University of Rome "Sapienza", Rome, Italy
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Altree TJ, Jersmann H, Nguyen P. Persistent air leak successfully treated with endobronchial valves and digital drainage system. Respirol Case Rep 2018; 6:e00368. [PMID: 30237889 PMCID: PMC6138541 DOI: 10.1002/rcr2.368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 08/22/2018] [Accepted: 08/26/2018] [Indexed: 11/23/2022] Open
Abstract
A 62-year old man with severe chronic obstructive pulmonary disease developed a persistent air leak from an iatrogenic pneumothorax following Computed Tomography-guided core biopsy of a pulmonary nodule. The pneumothorax was treated with an 8.5F intercostal catheter, which was then replaced by a 28F thoracostomy tube after development of significant subcutaneous emphysema and a tension pneumothorax. The air leak showed no improvement until endobronchial valve (EBV) insertion guided by objective flow data from a digital drainage system (DDS). The air leak subsequently reduced with -20 cmH2O suction from the DDS, and the thoracostomy tube was removed once the objective measured flow rate had sufficiently diminished. The combination of EBV insertion and suction from the DDS successfully treated the persistent air leak, with timing of thoracostomy tube removal guided by DDS flow data.
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Affiliation(s)
- Thomas James Altree
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Hubertus Jersmann
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
| | - Phan Nguyen
- Department of Thoracic MedicineRoyal Adelaide HospitalAdelaideSouth AustraliaAustralia
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48
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French DG, Plourde M, Henteleff H, Mujoomdar A, Bethune D. Optimal management of postoperative parenchymal air leaks. J Thorac Dis 2018; 10:S3789-S3798. [PMID: 30505566 DOI: 10.21037/jtd.2018.10.05] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Air leaks are the most common complication after pulmonary resection. Enhanced recovery after surgery (ERAS) programs must be designed to manage parenchymal air leaks. ERAS programs should consider two components when creating protocols for air leaks: assessment and management. Accurate assessment of air leaks using traditional analogues devices, newer digital drainage systems, portable devices and chest X-rays (CXR) are reviewed. Published data suggests that digital drainage systems result in a more confident assessment of air leaks. The literature regarding the management of postoperative air leaks, including the number of chest tubes, the role of applied external suction, invasive maneuvers and discharge with a portable device is reviewed. The key findings are that a single chest drain is adequate in the majority of cases to manage an air leak, the use of applied external suction is unlikely to prevent or prolong an air leak, autologous blood patch pleurodesis may potentially shorten postoperative air leaks and there is sufficient data to support that patients can safely be discharged with a portable drainage system. There is also literature to support the design of protocols for management of postoperative air leaks. Standardization of postoperative care through ERAS programs will allow for the design of larger RCTs to better understand some of the controversies around the management of postoperative air leaks.
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Affiliation(s)
- Daniel G French
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Madelaine Plourde
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Harry Henteleff
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Aneil Mujoomdar
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
| | - Drew Bethune
- Division of Thoracic Surgery, Department of Surgery, Queen Elizabeth II Hospital - Victoria Campus, Dalhousie University, Halifax, NS, Canada
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Majid A, Kheir F, Sierra-Ruiz M, Ghattas C, Parikh M, Channick C, Keyes C, Chee A, Fernandez-Bussy S, Gangadharan S, Folch E. Assessment of Fissure Integrity in Patients With Intrabronchial Valves for Treatment of Prolonged Air Leak. Ann Thorac Surg 2018; 107:407-411. [PMID: 30315804 DOI: 10.1016/j.athoracsur.2018.08.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/15/2018] [Accepted: 08/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intrabronchial valves (IBVs) are a treatment alternative for persistent air leak (PAL). However, there is a paucity of evidence regarding whether the absence of collateral ventilation (CV) can predict successful treatment of PAL with IBV placement. We assessed whether absence of CV measured by fissure integrity could predict successful resolution of PAL with IBV placement. METHODS A multicenter, retrospective study was performed. Patients who underwent IBV placement for PAL were identified. Chest computed tomography analysis via VIDA Diagnostics was used to assess CV. CV was present if the treated lobe was adjacent to a fissure that was <90% complete. RESULTS A total of 81 valves were placed in 26 patients (median, 3 per patient). A total of 16 patients without CV underwent IBV placement: 14 patients had complete resolution of PAL with a median time from IBV placement to air leak resolution of 4.5 days and 2 patients required subsequent procedures to manage the PAL. In a subset of patients without CV who underwent complete lobar occlusion with IBV (n = 8), median time to PAL resolution was 3 days, whereas in patients without CV who underwent incomplete lobar occlusion with IBV (n = 6), median time PAL resolution was 6.5 days (p = 0.045). All 10 patients with CV underwent IBV placement and complete lobar occlusion: 4 patients had complete PAL resolution with a median time from IBV placement to PAL resolution of 17.5 days and 6 patients required subsequent procedures to manage their PAL. CONCLUSIONS PAL treatment with IBV is more successful in patients without CV, especially when complete lobar occlusion with IBV is achieved.
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Affiliation(s)
- Adnan Majid
- Department of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | - Fayez Kheir
- Department of Pulmonary Critical Care and Environmental Health, Tulane University, New Orleans, Louisiana
| | - Melibea Sierra-Ruiz
- Department of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Christian Ghattas
- Department of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Mihir Parikh
- Department of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Colleen Channick
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Colleen Keyes
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Alex Chee
- Department of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | - Sidhu Gangadharan
- Department of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erik Folch
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
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50
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Pastis NJ, Yarmus LB, Schippers F, Ostroff R, Chen A, Akulian J, Wahidi M, Shojaee S, Tanner NT, Callahan SP, Feldman G, Lorch DG, Ndukwu I, Pritchett MA, Silvestri GA. Safety and Efficacy of Remimazolam Compared With Placebo and Midazolam for Moderate Sedation During Bronchoscopy. Chest 2018; 155:137-146. [PMID: 30292760 DOI: 10.1016/j.chest.2018.09.015] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/20/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND While the complexity of flexible bronchoscopy has increased, standard options for moderate sedation medications have not changed in three decades. There is a need to improve moderate sedation while maintaining safety. Remimazolam was developed to address shortcomings of current sedation strategies. METHODS A prospective, double-blind, randomized, multicenter, parallel group trial was performed at 30 US sites. The efficacy and safety of remimazolam for sedation during flexible bronchoscopy were compared with placebo and open-label midazolam. RESULTS The success rates were 80.6% in the remimazolam arm, 4.8% in the placebo arm (P < .0001), and 32.9% in the midazolam arm. Bronchoscopy was started sooner in the remimazolam arm (mean, 6.4 ± 5.82 min) compared with placebo (17.2 ± 4.15 min; P < .0001) and midazolam (16.3 ± 8.60 min). Time to full alertness after the end of bronchoscopy was significantly shorter in patients treated with remimazolam (median, 6.0 min; 95% CI, 5.2-7.1) compared with those treated with placebo (13.6 min; 95% CI, 8.1-24.0; P = .0001) and midazolam (12.0 min; 95% CI, 5.0-15.0). Remimazolam registered superior restoration of neuropsychiatric function compared with placebo and midazolam. Safety was comparable among all three arms, and 5.6% of the patients in the remimazolam group had serious treatment-emergent adverse events as compared with 6.8% in the placebo group. CONCLUSIONS Remimazolam administered under the supervision of a pulmonologist was effective and safe for moderate sedation during flexible bronchoscopy. In an exploratory analysis, it demonstrated a shorter onset of action and faster neuropsychiatric recovery than midazolam.
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Affiliation(s)
- Nicholas J Pastis
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC.
| | - Lonny B Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD
| | | | | | - Alexander Chen
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jason Akulian
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, NC
| | - Momen Wahidi
- Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Samira Shojaee
- Division of Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Nichole T Tanner
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
| | - Sean P Callahan
- Division of Pulmonary and Critical Care, Greenville Health System, Greenville, SC
| | | | - Daniel G Lorch
- Pulmonary Associates of Brandon Clinical Research, Brandon, FL
| | - Ikeadi Ndukwu
- LaPorte County Institute for Clinical Research, Michigan City, IN
| | - Michael A Pritchett
- Pulmonary and Critical Care Medicine, FirstHealth Moore Regional Hospital, and Pinehurst Medical Clinic, Pinehurst, NC
| | - Gerard A Silvestri
- Division of Pulmonary and Critical Care, Medical University of South Carolina, Charleston, SC
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