Use of a Removable Endobronchial Valve for the Treatment of Bronchopleural Fistula

A novel approach involving reversed placement of endobronchial valves combined with retrograde methylene blue instillation for the localization of multifocal bronchopleural fistula

The bronchopleural fistula (BPF) is a pathological communication between the bronchus and the pleural space. Diagnosing BPF poses a significant challenge for physicians, particularly when identifying multifocal BPFs. Traditionally, retrograde instillation of methylene blue (MB) into the pleural cavity with simultaneous observation with a bronchoscope has been used to locate a BPF. However, MB instillation is not effective in identifying multifocal BPFs. In this article, we report a new method for locating multifocal BPFs which involves placing the endobronchial valve (EBV) in reverse combined with retrograde MB instillation. First, the thoracic cavity is filled with MB solution. Then, using bronchoscopy, the location of a BPF can be identified as the MB solution flows into the bronchus. Secondly, an EBV is deployed in reverse in the bronchus where the identified BPF is located. Retrograde MB instillation is then repeated to locate any additional BPFs until no new ones are found. Two cases were reported using this novel method to identify multifocal BPFs, and each case was ultimately diagnosed with 2 BPFs. After precisely locating all the BPFs, the EBVs are then removed and placed forward in the target bronchi for treating the BPFs. During the follow-up period, no recurrence of BPFs was observed. We conclude that reversed placement of EBVs combined with retrograde MB instillation appears to be an effective approach for locating multifocal BPFs.

Use of endobronchial valve to treat COVID-19 adult respiratory distress syndrome-related alveolopleural fistula

Coronavirus disease-2019 (COVID-19) pneumonia is one of the severe and most dreaded forms of illness caused by severe acute respiratory syndrome coronavirus 2. It often progresses to respiratory failure and acute respiratory distress syndrome (ARDS) requiring mechanical ventilation. ARDS can lead to multiple complications while on mechanical ventilation due to positive airway pressures in a fibrotic lung, one such complication is the development of alveolopleural fistula. Alveolopleural fistula has high morbidity and mortality. We used endobronchial valve in a patient with COVID-19-related ARDS with persistent air leak (alveolopleural fistula), which allowed us to remove the chest tube and wean the patient successfully off mechanical ventilation.

Recent Advances in Interventional Pulmonology

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

Successful treatment of pyopneumothorax with bronchopleural fistula using endobronchial Watanabe spigots

Bronchopleural fistula (BPF) can complicate necrotizing pneumonia. Surgery would be indicated in patients who fail conservative management, yet this group is often of poor pulmonary function and general condition. Bronchial occlusion with endobronchial Watanabe spigots (EWS) can be a potential alternative treatment when the culprit bronchi can be isolated. In this case report, we describe a middle-aged gentleman who presented with necrotizing pneumonia complicated with pyopneumothorax with right upper lobe BPF, and who had failed to respond to chest drainage and antibiotics. EWS bronchial occlusion finally led to cessation of air leak, allowing removal of chest tube. EWS were removed uneventfully six months later. This case highlights the role of EWS in the management of BPF in patients with high surgical risk.

Endobronchial valves for persistent air leak all-cause mortality and financial impact: US trend from 2012-2016

Background: Endobronchial valves (EBV) are considered an innovation in the management of the persistent air leak (PAL). They offer a minimally invasive alternative to the traditional approach of pleurodesis and surgical intervention. We examined trends in mortality, length of stay (LOS), and resources utilization in patients who underwent EBV placement for PAL in the US.

Methods: We utilized discharge data from the Nationwide Inpatient Sample (NIS) for five years (2012–2016). We included adults diagnosed with a pneumothorax who underwent EBV insertion at ≥ 3 days from the day of chest tube placement; or following invasive thoracic procedure. We analyzed all-cause mortality, LOS, and resources utilization in the study population.

Results: A total of 1,885 cases met our inclusion criteria. Patients were mostly middle-aged, males, whites, and had significant comorbidities. The average LOS was 21.8 ± 20.5 days, the mean time for chest tube placement was 3.8 ± 5.9 days, and the mean time for EBV insertion was 10.5 ± 10.3 days. Pleurodesis was performed before and after EBV placement and in 9% and 6%, respectively.

Conclusions: Our study showed that the all-cause mortality rate fluctuated throughout the years at around 10%. Despite EBV being a minimally invasive alternative, its use has not trended up significantly during the study period. EBVs are also being used off-label in the US for spontaneous pneumothorax. This study shall provide more data to the scarce literature about EBV for PAL.

Intrabronchial Valves for Air Leaks After Lobectomy, Segmentectomy, and Lung Volume Reduction Surgery

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.

Endobronchial one-way valves for treatment of persistent air leaks: a systematic review

Persistent air leak (PAL) is associated with significant morbidity and mortality, prolonged hospitalization and increased health-care costs. It can arise from a number of conditions, including pneumothorax, necrotizing infection, trauma, malignancies, procedural interventions and complications after thoracic surgery. Numerous therapeutic options, including noninvasive and invasive techniques, are available to treat PALs. Recently, endobronchial one-way valves have been used to treat PAL. We conducted a systematic review based on studies retrieved from PubMed, EMbase and Cochrane library. We also did a hand-search in the bibliographies of relevant articles for additional studies. 34 case reports and 10 case series comprising 208 patients were included in our review. Only 4 patients were children, most of the patients were males. The most common underlying disease was COPD, emphysema and cancer. The most remarkable cause was pneumothorax. The upper lobes were the most frequent locations of air leaks. Complete resolution was gained within less than 24 h in majority of patients. Complications were migration or expectoration of valves, moderate oxygen desaturation and infection of related lung. No death related to endobronchial one-way valves implantation has been found. The use of endobronchial one-way valve adds to the armamentarium for non-invasive treatments of challenging PAL, especially those with difficulties of anesthesia, poor condition and high morbidity. Nevertheless, prospective randomized control trials with large sample should be needed to further evaluate the effects and safety of endobronchial one-way valve implantation in the treatment of PAL.

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

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

Endobronchial-Guided Vascularized Tissue Flaps for a Bronchopleural Fistula

The management of bronchopleural fistulas can be challenging. The initial treatment is usually conservative, but operative intervention with transposition of vascularized pedicled flaps may be required in refractory cases. We present the case of a 67-year-old man with stage IIIa squamous cell carcinoma of the lung who underwent a lower and middle bilobectomy after receiving neoadjuvant chemoradiation. His postoperative course was complicated by empyema and a bronchopleural fistula. Because of difficulty accessing the fistula, endobronchial-guided vascularized tissue flaps were successfully used to close the fistula.

Bronchoscopic valves for prolonged air leak: current status and technique

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Historical perspectives of bronchoscopy. Connecting the dots

The era of bronchoscopy began with Gustav Killian in 1876 when he removed a pork bone from a farmer's airway, using an esophagoscope. Prompted by this accomplishment, Chevalier Jackson, an American otolaryngologist, laid the platform for the modern-day rigid bronchoscope in the early twentieth century. In 1967 Shigeto Ikeda revolutionized the field of bronchoscopy by his innovation of the fiberoptic bronchoscope. Today, bronchoscopy and interventional pulmonology have become an integral part of pulmonary medicine and an established subspecialty. Numerous innovators have furthered the horizons of this technology. In the early 1980s Ko-Pen Wang introduced transbronchial needle aspiration to sample mediastinal lesions while Jean-François Dumon developed methods for laser photoresection and for placing stents thorough the bronchoscope. More recently, application of endobronchial ultrasound and electromagnetic navigation tools has further galvanized the role of bronchoscopy. The success of lung transplantation also belongs in part to flexible bronchoscopy. Today, researchers are looking into treating emphysema as well as asthma, using bronchoscopic techniques. We believe 2015 is a good time to look back on the history of bronchoscopy and to recognize its major milestones. This article attempts to connect the historical dots in this field of research, with the hope that our effort helps future generations improve the welfare of patients with lung ailments.

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

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

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

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

METHODS

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

RESULTS

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

CONCLUSION

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

Endobronchial Valves for Challenging Air Leaks

BACKGROUND

Prolonged air leaks may result in increased morbidity and mortality. Endobronchial valves have been used as a nonoperative treatment. We evaluated the efficacy of endobronchial valves at achieving chest tube removal and hospital discharge for air leaks resulting from varied etiologies.

METHODS

All consecutive patients undergoing endobronchial valve placement for persistent air leak were evaluated by a multidisciplinary team at a single institution. Those receiving valves underwent bronchoscopy with balloon occlusion to identify airways contributing to the leak. After airway sizing, unidirectional endobronchial valves were deployed.

RESULTS

During an 18-month period, 21 patients underwent 24 valve placement procedures; 88 valves were placed (median, 3; mean, 3.6; range, 1 to 12). Patient age range was 16 months to 70 years. The underlying cause of persistent air leak was postoperative (n = 8), pneumothorax (n = 11), cavitary lung infection (n = 3), and postpneumonectomy bronchopleural fistula (n = 2). There were no valve-related complications during placement, dwell time, or removal. Three patients died as a result of their underlying disease, unrelated to valves. Of those with chest tubes who survived and were discharged, all had successful removal of their chest tubes. Median duration to chest tube removal after initial valve placement was 15 days (mean, 21 days; range, 0 to 86 days). Median length of stay after final valve placement was 5 days (mean, 15 days; range, 0 to 196 days).

CONCLUSIONS

Challenging air leaks often occur in medically compromised patients. They may persist despite multiple interventions. Endobronchial valves offer minimally invasive management. Time to chest tube removal and length of stay are variable, frequently because of clinical status and underlying disease.

Treatment of alveolar-pleural fistula with endobronchial application of synthetic hydrogel

BACKGROUND

Alveolar-pleural fistula with persistent air leak is a common problem causing significant morbidity, prolonged hospital stay, and increased health-care costs. When conventional therapy fails, an alternative to prolonged chest-tube drainage or surgery is needed. New bronchoscopic techniques have been developed to close the air leak by reducing the flow of air through the leak. The objective of this study was to analyze our experience with bronchoscopic application of a synthetic hydrogel for the treatment of such fistulas.

METHODS

We conducted a retrospective study of patients with alveolar-pleural fistula with persistent air leaks treated with synthetic hydrogel application via flexible bronchoscopy. Patient characteristics, underlying disease, and outcome of endoscopic treatment were analyzed.

RESULTS

Between January 2009 and December 2013, 22 patients (14 men, eight women; mean age ± SD, 62 ± 10 years) were treated with one to three applications of a synthetic hydrogel per patient. The primary etiology of persistent air leak was necrotizing pneumonia (n = 8), post-thoracic surgery (n = 6), bullous emphysema (n = 5), idiopathic interstitial pneumonia (n = 2), and sarcoidosis (n = 1). Nineteen patients (86%) had complete resolution of the air leak, leading to successful removal of chest tube a mean ( ± SD) of 4.3 ± 0.9 days after last bronchoscopic application. The procedure was very well tolerated, with two patients coughing up the hydrogel and one having hypoxemia requiring bronchoscopic suctioning.

CONCLUSIONS

Bronchoscopic administration of a synthetic hydrogel is an effective, nonsurgical, minimally invasive intervention for patients with persistent pulmonary air leaks secondary to alveolar-pleural fistula.

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

Background

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

Material/Methods

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

Results

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

Conclusions

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

Rescue therapy using an endobronchial valve and digital air leak monitoring in Invasive Pulmonary Aspergillosis

In this case report, we describe the utilisation of two recently developed technologies for the successful management of a persistent air leak (PAL) in a critically ill patient in whom cardiothoracic surgical intervention was not possible. We report the case of a young leukaemic woman with a PAL complicating Invasive Pulmonary Aspergillosis (IPA), who was effectively managed using an Endobronchial Valve, supplemented by objective, digital air leak data provided by a Thopaz^® device (Medela, Switzerland).

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Endobronchial valve placement for spontaneous pneumothorax from stage IIIA non-small cell lung cancer facilitates neoadjuvant therapy

Spontaneous pneumothorax has previously been described as a presenting symptom of lung cancer. This presentation can, unfortunately, complicate and delay further definitive oncologic care until the pneumothorax can be effectively managed. We describe the case of a 58-year-old man who presented with secondary spontaneous pneumothorax and persistent air leak related to his primary lung carcinoma. Endobronchial valve placement allowed for the avoidance of pleurodesis, timely discharge, and neoadjuvant chemotherapy, followed by definitive surgical resection.

Endobronchial valve placement and balloon occlusion for persistent air leak: procedure overview and new current procedural terminology codes for 2013

Unidirectional endobronchial valves, originally studied for potential treatment of emphysema, have emerged as a useful intervention for patients with persistent air leak from the lung. The procedure is accomplished via bronchoscopy in a patient who already has a chest tube in place for management of the air leak. It uses an occluding balloon to determine the specific airway(s) leading to the leak by impact on airflow and subsequent placement of removable valve(s) in one or more segment or subsegments to decrease flow across the leak to allow for healing of the fistula. Specific US Food and Drug Administration-approved criteria for placement and removal of these valves via a Humanitarian Device Exemption are discussed along with reported outcomes. Current Procedural Terminology codes effective for 2013 that are specific to the procedure are reviewed.

Endobronchial valves in the management of recurrent haemoptysis

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

Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients

BACKGROUND

Bronchopleural fistulas (BPF) are conditions associated with prolonged hospital course, high morbidity, and possibly increased mortality. The presence of BPFs in critically ill patients may cause difficulty in ventilation and increased oxygen requirements. Intrabronchial valves (Spiration IBV) serve as a noninvasive therapeutic option for the closure of BPFs.

METHODS

This report is a retrospective description of 3 patients transferred to our medical intensive care unit (ICU) with BPFs and persistent air leaks (PAL). One patient required high levels of oxygen supplementation through a nonrebreather face mask, whereas 2 required mechanical ventilation because of respiratory failure. IBVs were placed in each patient with the intention of closing their BPF and weaning them from respiratory support.

RESULTS

The use of IBVs in ICU patients with BPFs and PALs resulted in 1 patient being weaned from the persistent need for a nonrebreather face mask to room air and also aided in the liberation from mechanical ventilation of 2 patients who had been failing spontaneous breathing trials.

CONCLUSIONS

The use of IBVs is safe and well tolerated in ICU patients with BPFs and PALs. The placement of IBVs results in significant clinical improvement, allowing for either weaning from high levels of oxygen support or liberation from mechanical ventilation.

Interventional pulmonology

Interventional pulmonology is a rapidly growing field of pulmonary medicine. It is a procedure-based subspecialty focusing on minimally invasive advanced diagnostic and therapeutic interventions. Current interventions include advanced bronchoscopic imaging, guidance methods for diagnostic bronchoscopy, therapeutic modalities for central airway obstructions, pleural interventions, and novel therapies for asthma and chronic obstructive pulmonary disease. This article is an introduction to pertinent interventions within the context of the diseases encountered by the trained interventional pulmonologist.

Endoscopic lung volume reduction effectively treats acute respiratory failure secondary to bullous emphysema

Emphysema often affects the lungs in a heterogeneous fashion, and collapse or removal of severely hyperinflated portions of lung can improve overall lung function and symptoms. The role of lung volume reduction (LVR) surgery in selected patients is well established, but that of non-surgical LVR is still being defined. In particular, use of endobronchial LVR is still under development. This case report describes a 48-year-old non-smoker with severe bullous emphysema complicated by acute hypercapnic respiratory failure, who was successfully treated by endobronchial valve placement while intubated in an intensive care unit.

Iatrogenic air leak successfully treated by bronchoscopic placement of unidirectional endobronchial valves

This report describes a patient with persistent air leak after inadvertent placement of a chest drain in a bulla. Chest drain and suction failed to stop the air leak, whereas the surgical repair was judged to be excessively aggressive. In closure, two large endobronchial valves were sequentially positioned in the superior and inferior division of the left upper lobe to completely close it. The result was the collapse of bulla with closure of fistula and complete lung expansion.

Emerging technologies for the thorax: indications, management and complications

The field of interventional pulmonology has rapidly expanded to include the management and treatment of complex diseases of the chest. The management of central airway obstruction, pleural disease diagnosis, treatment and palliation, advanced bronchoscopic techniques to aid in the diagnosis of lung cancer and innovative therapies to treat asthma and COPD have all emerged over the past decade. As astute clinicians, we are all aware of the risks and benefits of using these therapies to treat our patients. In order to appropriately treat and manage these often complex medical situations, the physician should have an expert knowledge of all available modalities, the expertise to safely perform the procedure and the ability to minimize the risk of and manage the associated complications that may arise. In this chapter we review and update some of the bronchoscopic and pleural interventions offered by interventional pulmonologists as well as the associated complications and management.

Emergency use of an endobronchial one-way valve in the management of severe air leak and massive subcutaneous emphysema

Bronchopleural (BPF) and alveolar-pleural (APF) fistulas are frequently encountered in clinical practice with persistent air leaks that can lead to significant morbidity, prolonged hospital stay, and potentially increased mortality. BPF and APF are commonly related to pulmonary resections. Other etiologies include minimally invasive procedures (thoracentesis and image-guided biopsies), and spontaneous fistulas related to an underlying structural lung disease (e.g., emphysema) or a necrotizing pulmonary process (e.g., infection or malignancy). Radiofrequency ablation for pulmonary malignancies is an effective modality that can rarely lead to APF with persistent air leak. Surgical intervention remains the standard treatment option for BPF and APF. A variety of minimally invasive bronchoscopic approaches can be considered for selected nonsurgical candidates. The use of one-way endobronchial valves to manage severe and persistent air leaks can be considered a minimally invasive option in selected patients. The valves selectively block inspiratory airflow to a specific segmental or subsegmental airway but allow expiratory flow with drainage of air and secretions from the corresponding distal airways and lung parenchyma.

Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device

Bronchopleural fistula may be treated by medical, endoscopic, and surgical techniques, but large fistulas remain a challenge to be closed using endoscopic techniques. We describe the endoscopic closure of a bronchial total fistula with the Occlutech Figulla ASD N device (International Occlutech AB, Helsingborg, Sweden), originally designed for closure of an atrial septal defect. The procedure was conducted without general anesthesia or rigid bronchoscopy, bronchography, or radioscopy. An immediate reduction in the air leak was observed and also later on bronchoscopy, as the device was almost covered by granulation tissue. The endobronchial technique described seems to be safe and effective to manage large bronchopleural fistulas.

Bronchopleural fistula: an update for intensivists

Bronchopleural fistula is a potentially fatal condition that may result after a variety of clinical conditions, most commonly after pulmonary resection. Either surgical or bronchoscopic repair is required to definitively correct these lesions, though a small number may resolve spontaneously with optimal ventilatory care and other options available to an intensivist in the management of this complex condition. The successful management of a bronchopleural fistula depends on formulating a treatment strategy tailored to individual patient needs.

Bronchoscopic lung volume reduction: indications, effects and prospects

PURPOSE OF REVIEW

Despite optimal pharmacological treatment, many patients with chronic obstructive pulmonary disease remain very disabled. Bronchoscopic lung volume reduction involves the insertion of valves into the airways supplying emphysematous areas of lung with the intention of causing atelectasis and thus improving operating lung volumes. Bronchoscopic techniques are less hazardous than lung volume reduction surgery.

RECENT FINDINGS

Case series in the literature are reviewed. The presence of extensive pathological collateral ventilation, particularly in patients with homogeneous disease, means that atelectasis occurs relatively infrequently even with complete lobar occlusion. Benefit is greatest in the presence of atelectasis but does not occur only in this group of patients. Endobronchial valves have also been used to treat persistent air leaks in a number of clinical contexts.

SUMMARY

A number of case series have been published which show promise and the results of a large multicentre randomized controlled study are anticipated in 2007. A number of other bronchoscopic treatments for emphysema are also under development, including airway bypass techniques and tissue glues.