Clinical evaluation of endoscopic bronchial occlusion with silicone spigots for the management of persistent pulmonary air leaks

Endobronchial silicone spigot in prolonged air leaks: Nationwide study on outcomes and risk factors for treatment failure

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.

A case of attempted transbronchial spigot insertion for fistulous pyothorax in the residual pleural airspace after pleurectomy/decortication for malignant pleural mesothelioma

Pleurectomy/decortication for malignant pleural mesothelioma is a relatively recent surgical approach for which there is a dearth of information on complications, especially in the late postoperative period. A 70-year-old man was diagnosed with right epithelioid malignant pleural mesothelioma and underwent pleurectomy/decortication. Computed tomography at 6 months after surgery revealed nodules on the surface of the right lung. These nodules gradually increased in size and were diagnosed as recurrent disease. Immunotherapy was started, but treatment was discontinued a few days after the first course due to pneumonitis. Subsequent oral prednisolone therapy for about 2 months ameliorated pneumonitis, but fistulous pyothorax developed. During attempted transbronchial occlusion of the responsible bronchus, some spigots penetrated the empyema cavity. Open window thoracotomy was performed on the following day. This case suggests that if there is no change in diameter between the proximal and distal parts of the responsible bronchus, transbronchial occlusion should not be chosen.

Utility of the endobronchial Watanabe spigot for intractable cancer-related pneumothorax: a retrospective observational study

BACKGROUND

The use of endobronchial Watanabe spigots for intractable secondary pneumothorax in patients with cancer has not been adequate. This study aimed to investigate the use of endobronchial Watanabe spigots for intractable pneumothorax in patients with malignant tumors.

METHODS

Consecutive patients with malignant tumors who underwent occlusion with an endobronchial Watanabe spigot for intractable pneumothorax associated with perioperative treatment or drug therapy at our institution between January 2014 and February 2022 were reviewed.

RESULTS

Of the 32 cases in which an endobronchial Watanabe spigot was used, six were excluded; we thus evaluated 26 cases in which the chest tube was removed. Chest tubes were removed in 19 cases (73.1%) and could not be removed and required surgical treatment under general anesthesia in seven patients (26.9%), of which four (14.8%) underwent open-window thoracostomy. Half of the patients were treated with both an endobronchial Watanabe spigot and pleurodesis. Although thin-slice chest computed tomography revealed a fistula in 15 patients, the chest tube was removed in 11 (57.9%) patients. A significant difference was only observed in patients with a history of heavy smoking.

CONCLUSIONS

The chest tube removal rate was comparable to those reported in previous studies. An endobronchial Watanabe spigot may be a useful treatment option for intractable cancer-related pneumothorax.

Endobronchial Watanabe Spigot Placement for Hepatic Abscess and Bronchobiliary Fistula Following Radiofrequency Ablation for Hepatocellular Carcinoma

A bronchobiliary fistula (BBF) is an uncommon but severe complication after radiofrequency ablation (RFA). However, the definitive salvage methods are controversial. We herein report a patient with hepatocellular carcinoma with hepatic abscess and BBF following RFA. We also review previous reports of BBF after RFA. The patient was a man in his 70s who underwent RFA for recurrent hepatocellular carcinoma in the subphrenic area. Despite percutaneous transhepatic abscess drainage, bilioptysis persisted. Finally, the BBF was occluded with an endobronchial Watanabe spigot under fiber-optic bronchoscopy. Placing an endobronchial Watanabe spigot should be considered as a salvage therapy for refractory BBF following RFA.

Bronchoscopic Treatment of Giant Emphysematous Bullae with Endobronchial Silicone Plugs

Purpose

Surgical bullectomy is the standard treatment of giant emphysematous bulla (GEB). However, bronchoscopic treatment should be considered as an alternative approach for patients who are unfit for surgical treatment. The study aimed to evaluate the clinical efficacy of endobronchial occlusion for the treatment of GEB using silicone plugs.

Methods

This retrospective study recruited four patients with GEB who were unsuitable for surgery. Preoperative planning was performed using high-resolution computed tomography and a virtual bronchoscopic navigation system. Customized silicone plugs were then placed in the target airway via bronchoscopy to cause GEB regression and atelectasis.

Results

All procedures were completed successfully in four patients. Three months after the procedures, compared with baseline, increases in the mean forced expiratory volume in 1 s (from 1.20 L/s to 1.33 L/s), forced vital capacity (from 2.63 L to 2.90 L), diffusion lung capacity for carbon monoxide (from 29% to 41% of the predicted value) and 6-minute walking test (from 412 m to 474 m) were observed. Additionally, the mean total lung capacity (from 6.80 L to 6.35 L), residual volume (from 3.97 L to 3.52 L), and St. George’s Respiratory Questionnaire scores (from 67 to 45) were all lower than baseline data.

Conclusion

Our preliminary results demonstrated that the endobronchial placement of silicone plugs could be a low-cost, safe, and effective choice for the treatment of GEB in surgically unfit patients.

Pleurodesis After Bronchial Occlusion for Inoperable Secondary Spontaneous Pneumothorax

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.

Endobronchial Watanabe spigot complementing prophylactic balloon blocker in the management of post-transbronchial cryobiopsy bleeding

Transbronchial cryobiopsy (TBCB) is performed to aid diagnosis of interstitial lung disease, of which bleeding is a potentially life-threatening complication. Post-TBCB management involves temporary balloon blockade, bronchial artery embolisation (BAE) or surgery. Bronchial occlusion by endobronchial Watanabe spigot (EWS) as the definitive method of bleeding control post TBCB has not been described. A 56-year-old male underwent TBCB to aid diagnosis of interstitial lung disease. TBCB had been performed at RB4 (lateral segment of right middle lobe) with a prophylactic balloon blocker. However, prolonged bleeding was observed upon deflation of the balloon blocker. Haemostasis was secured with successful deployment of EWS into RB4, with no evidence of rebleeding in surveillance bronchoscopy and chest radiographs. EWS was kept in situ for four days and subsequently removed. The patient was discharged with good functional status. This case demonstrates that EWS placement may be considered for definitive management of low-volume post-TBCB bleeding, especially when BAE and surgical intervention are not possible.

Pneumothorax in patients with idiopathic pulmonary fibrosis: a real-world experience

Background

Some patients with idiopathic pulmonary fibrosis (IPF) develop pneumothorax. However, the characteristics of pneumothorax in patients with IPF have not been elucidated. The purpose of this study was to clarify the clinical course, actual management, and treatment outcomes of pneumothorax in patients with IPF.

Methods

Consecutive patients with IPF who were admitted for pneumothorax between January 2008 and December 2018 were included. The success rates of treatment for pneumothorax, hospital mortality, and recurrence rate after discharge were examined.

Results

During the study period, 36 patients with IPF were admitted with pneumothorax a total of 58 times. During the first admission, 15 patients (41.7%) did not receive chest tube drainage, but 21 (58.3%) did. Of the 21 patients, 8 (38.1%) received additional therapy after chest drainage. The respective treatment success rates were 86.6% and 66.7% in patients who underwent observation only vs chest tube drainage. The respective hospital mortality rates were 13.3% and 38.0%. The total pneumothorax recurrence rate after hospital discharge was 34.6% (n = 9).

Conclusions

Pneumothorax in patients with IPF was difficult to treat successfully, had a relatively poor prognosis, and showed a high recurrence rate.

Toward Easy and Rapid Bronchial Occlusion With an Endobronchial Watanabe Spigot: A New Technique Using a Guide Sheath and Curette

BACKGROUND

Bronchial occlusion using an endobronchial Watanabe spigot (EWS) is reportedly effective for intractable bronchopleural fistula. Here, we describe a rapid and easy method for bronchial occlusion using a guide sheath (GS) and curette.

METHODS

Thirty consecutive patients who underwent bronchial occlusion under mild sedation between October 2014 and February 2018 were enrolled. The devices used were a flexible bronchoscope (BF-1T260 or BF-1TQ290), GS (SG-201C; with 30 mm of the proximal end cutaway), and a CC-4CR-1 curette (all supplied by Olympus Ltd). The curette was inserted into the GS with the tip of the curette exposed outside the GS. The curette and GS were inserted into the bronchoscope. The EWS attached to the curette tip was inserted into the target bronchus and left in position by pulling the curette back through the GS while pushing the EWS with the GS under the bronchoscopic view. The success rate and procedure time were recorded.

RESULTS

Bronchial occlusion with an EWS was performed on 143 target bronchi (2 to 9 bronchi/patient). The bronchial occlusion success rate was 98.6%. The median procedure time for bronchial occlusion per EWS on video recordings of the 10 most recent procedures was 110 (range, 40 to 521) seconds. The target bronchial occlusion success rate was 100%. This method enabled easy insertion of the EWS, even in the sharply branching upper lobe bronchus. No complications were observed.

CONCLUSION

Bronchial occlusion using a GS and curette is a rapid and easy technique even in a sharply branching target bronchus.

Refractory secondary pneumothorax complicated with lung cancer treated by bronchial occlusion: a case report

Background

Pneumothorax is defined as the presence of air or gas in the pleural cavity. Secondary pneumothorax usually occurs in patients with overt underlying lung disease, most commonly chronic obstructive pulmonary disease (COPD). Patients with poor lung function often suffer from pneumothorax with a persistent air leak. Various strategies have been employed in the treatment of such refractory pneumothorax. Bronchial occlusion with an Endobronchial Watanabe Spigot (EWS) (Novatech, Grasse, France) has been shown to be useful in treating prolonged bronchopleural fistulas. Although the effects of bronchial occlusion with EWS are known, refractory pneumothorax often involves multiple affected bronchi, and in some cases the affected bronchi cannot be easily identified. In addition, secondary pneumothorax associated with advanced lung cancer often prolongs the treatment of pneumothorax, which can significantly reduce patients’ quality of life and prognosis.

Case presentation

We report a case of refractory pneumothorax where collateral ventilation was successfully treated by bronchial occlusion of the affected bronchi using multiple methods. In August 2019, an 80-year-old Japanese man with asthma and COPD overlap was admitted for exacerbation triggered by respiratory tract infection. During hospitalization, he presented with chest pain due to pneumothorax. Subsequently, a chest drain tube was inserted and pleurodesis was performed; however, the lung could not be sufficiently expanded and an air leak remained. Further investigation revealed a tumor suspicious for lung cancer at the entrance of the left upper lobe bronchus. Due to poor lung function, surgical treatments were deemed high risk. Therefore, we performed bronchial occlusion using the Endobronchial Watanabe Spigot (EWS). Because we could not determine the affected bronchi by computed tomography (CT), we located the affected bronchi by balloon occlusion test and bronchography with iopamidol. After occlusion, the air leak decreased but still persisted. Thus, we performed pleurodesis twice, and the air leak ceased completely.

Conclusions

Refractory secondary pneumothorax, which affected multiple bronchi and developed into collateral ventilation due to lung cancer, was treated successfully with bronchial occlusion and EWS. In cases where the affected bronchi cannot be determined by the balloon occlusion test, bronchography with iopamidol might be an effective treatment.

Clinical Evaluation of Endoscopic Bronchial Occlusion with an Endobronchial Watanabe Spigot for the Management of Intractable Pneumothorax, Pyothorax with Bronchial Fistula, and Postoperative Air Leakage

Objective The present study aimed to evaluate the clinical effectiveness of endoscopic bronchial occlusion (EBO) with endobronchial Watanabe spigots (EWSs) for the management of prolonged pulmonary air leaks, such as intractable pneumothorax, pyothorax with bronchial fistula, and postoperative air leakage. Methods This was a retrospective study. Between April 2005 and March 2018, we recruited 21 patients with intractable pneumothorax (10 cases), pyothorax with bronchial fistula (7 cases), and postsurgical pulmonary fistula (4 cases) in whom appropriate drainage for 2 weeks had been unsuccessful and who were unsuitable for surgery. An EWS was inserted using a flexible bronchoscope via an endotracheal or a tracheostomy tube. Results The mean number of sessions with EWS procedures was 1.94, and the mean number of inserted EWS per patient was 6.5. In addition to EWS procedures, pleural washing and pleural adhesion therapy were performed in all cases with pyothorax, whereas pleural adhesion therapy was performed in three patients with pneumothorax. The successful treatment rate was 85.7%. Reduction of air leakage was observed in 19/21 patients. The mean duration of reduction of air leaks was 4.1 days (median, 1; range, 0-24 days) following EWS procedures. The mean duration from tube insertion to chest tube removal was 43.4 days (median, 29; range, 16-105 days). Complications included spigot migration and infection (aspergillosis); no complications caused significant mortality. Conclusion Performing EBO using an EWS appears to be a reasonable option for the management of intractable pneumothorax, pyothorax with pulmonary fistula, and postoperative air leakage.

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

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

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.

Management of Persistent Air Leaks Using Endobronchial Autologous Blood Patch and Spigot Occlusion: A Multicentre Randomized Controlled Trial in China

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.

Use of endo-bronchial end-tidal CO2 test for location of the pleural air leakage in patients with intractable pneumothorax

Background:

Location of the affected bronchus of pleural air leaks is the most important step of trans-bronchoscopic bronchial occlusion for the treatment of intractable pneumothorax. The balloon occlusion test is the most commonly used technique, but has failed in some cases. The aim of the present study was: (1) to determine if endo-bronchial end-tidal CO₂ (EtCO₂) measurement can identify the affected bronchus that is the source of a persistent pleural air leak; and (2) to establish a methodology for endo-bronchial EtCO₂ testing in locating affected bronchus in intractable pneumothorax.

Methods:

A total of 28 patients with intractable pneumothorax underwent bronchoscopy with (1) the balloon occlusion test for the identification of the affected bronchus; and (2) endo-bronchial EtCO₂ measurement (EtCO₂ test) at the orifices of the bronchus of the affected lung. The effectiveness of these two methods of affected bronchus identification were compared. The threshold EtCO₂ (T-EtCO₂) was determined.

Results:

The positive rates of locating the affected bronchus by the endo-bronchial EtCO₂ test, balloon occlusion test, and combination of the two techniques were 60.7% (17/28), 64.3% (18/28) and 96.4% (27/28), respectively. The average differences in EtCO₂ between the affected bronchus and the main carina, main bronchus, and non-affected bronchus were (in mmHg) 4.41 ± 1.99 (95% confidence interval: 3.5, 5.3), 4.73 ± 2.10 (3.80, 5.66 ) and 5.57 ± 2.53 (4.45, 6.69), respectively.

Conclusions:

(1) The endo-bronchial EtCO₂ test is complementary to the balloon occlusion test of the leading bronchus. (2) A threshold (T-EtCO₂) value of >5 mmHg is optimal for this technique.

Aorto-pleural fistula successfully treated by one-lung ventilation and Endobronchial Watanabe Spigots

Aorto-pleural fistula (APF) is a rare, potentially fatal condition that should be immediately treated by an endovascular or surgical approach. In this case, we treated APF using bronchial occlusion with Endobronchial Watanabe Spigots (EWSs) after one-lung ventilation. Notably, EWS is composed of silicon for endobronchial occlusion under bronchoscopy. An 88-year-old man was referred to our hospital for sudden massive hemoptysis. We maintained the airway by emergent intubation into the right main bronchus through guided bronchoscopy. Computed tomography demonstrated an aortic aneurysm at the aortic arch, penetrating the upper lobe of the left lung. On the 18th hospital day, we performed prophylactic endobronchial occlusion with EWS. The patient was extubated shortly thereafter. Endobronchial occlusion with EWS might be effective in patients with APF who exhibit generally poor conditions. Endobronchial occlusion treatment should be performed after controlling massive bleeding by one-lung ventilation.

Successful Long-term Management of Two Cases of Moderate Hemoptysis Due to Chronic Cavitary Pulmonary Aspergillosis with Bronchial Occlusion Using Silicone Spigots

Chronic pulmonary aspergillosis is a major cause of life-threatening hemoptysis. In symptomatic patients with simple aspergillomas, surgery is the main therapeutic method for preventing or treating life-threatening hemoptysis. However, the risks of both death and complications are higher in chronic cavitary pulmonary aspergillosis than in simple aspergilloma. We herein report two patients with persistent moderate hemoptysis due to chronic cavitary pulmonary aspergillosis who were not indicated for surgery, but were able to undergo successful long-term management with bronchial occlusion using silicone spigots. In diseases with a high recurrence rate of hemoptysis, the continuous placement of silicone spigots might therefore be effective to prevent rebleeding.

Bronchoscopic valve placement for the treatment of persistent air leaks

Persistent air leaks (PALs) are associated with increased morbidity, prolonged hospital stay, and increased treatment costs. Endobronchial 1-way valves have been recently used as a potential less invasive treatment option. We sought to investigate the effects of valve therapy in treating this condition. The patients with evidence of continuous air leak flow whose chest tubes remained in place for more than 7 days were treated with bronchoscopic closure using 1-way valves. The source of the air leak was identified by the Chartis system.A total of 11 patients (1 woman, 10 men; mean age, 68 years) who underwent valve placement were eligible to be enrolled from January 2015 through January 2017. Six patients had postoperative PAL, and 5 had a secondary spontaneous pneumothorax. The number of used valves varied from 1 to 3 (median 1). The resolution of the leak was complete in 8 patients (72.7%), whose mean duration of air leak before and after valve deployment was 58.5 and 4.5 days, respectively. There were no complications related to the valve deployment.Bronchoscopic placement of 1-way valves is a safe procedure that could help manage patients with prolonged PALs. A prospective randomized trial with cost-efficiency analysis is necessary to better define the role of this bronchoscopic intervention and demonstrate its effect on air leak duration.

Endoscopic bronchial occlusion for postoperative persistent bronchopleural fistula with computed tomography fluoroscopy guidance and virtual bronchoscopic navigation: A case report

RATIONALE

The development of postoperative bronchopleural fistula (BPF) remains a challenge in thoracic surgery. We herein report a case of BPF successfully treated with endoscopic bronchial occlusion under computed tomography (CT) fluoroscopy and virtual bronchoscopic navigation (VBN).

PATIENT CONCERNS

A 63-year-old man underwent right upper lobectomy with concomitant S6a subsegmentectomy for lung adenocarcinoma. On postoperative day 24, he complained of shaking chills with high fever.

DIAGNOSES

BPF with subsequent pneumonia and empyema.

INTERVENTIONS

Despite aggressive surgical interventions for the BPF, air leakage persisted postoperatively. On days 26 and 34 after the final operation, endobronchial occlusions were performed under CT fluoroscopy and VBN.

OUTCOMES

The air leaks greatly decreased and the patient was discharged.

LESSONS

CT fluoroscopy and VBN can be useful techniques for endobronchial occlusion in the treatment of BPF.

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.

Endoscopic occlusion with silicone spigots for the closure of refractory esophago-bronchiole fistula after esophagectomy

A 65-year-old man with cT1bN0M0 stage I middle thoracic esophageal cancer underwent subtotal esophagectomy and gastric tube reconstruction through the posterior mediastinal route after preoperative carbon-ion radiotherapy and chemotherapy in a clinical trial. Anastomotic leakage occurred, but it spontaneously improved. At six months after the operation, he was rehospitalized with a cough and dysphagia. An esophago-bronchiole fistula and stenosis of the gastric tube were observed. He first underwent stent placement in the gastric tube. Two weeks later, the syringeal epithelium was burned by argon plasma coagulation after stent removal. Endoscopic occlusion was then performed for the fistula with two guidewire-assisted silicone spigots. Two weeks later, he was discharged on an oral diet, and he has not developed recurrence of the fistula or cancer for three years. This is the first report of endoscopic occlusion with a guidewire-assisted silicone spigot through the esophagus.

Endobronchial embolization for life-threatening hemoptysis with Endobronchial Watanabe Spigot

Background

Massive hemoptysis is a common encounter in respiratory medicine. Bronchoscopy plays an important role in localizing the origin of bleeding, as well as endoscopic treatment of centrally located lesions. Endobronchial embolization is a novel technique enabling the management of hemoptysis arising even from peripheral lesions, via occlusion of the culprit bronchus, thereby securing the airway. Endobronchial Watanabe Spigot had been advocate in the treatment of bronchopleural fistula and the use of this novel technique had since then been expanded into the management of massive hemoptysis. To the best of our knowledge, this is the first reported case in Malaysia.

Case presentation

78-year-old lady who presented with life-threatening hemoptysis leading rapidly to cardiac arrest upon arrival. Spontaneous circulation was restored after resuscitation with an urgent thoracic computed tomography angiogram revealed bleeding likely from the posterior basal segment of left lower lobe, with bronchiectatic changes. Urgent flexible bronchoscopy revealed airway flooding, with bleeding originating from the lingular and posterior-basal segment of the left lower lobe. Airway toileting was performed and two 7 mm Endobronchial Watanabe Spigots were plugged into the culprit bronchi. Urgent bronchial artery embolization was then attempted, but was unsuccessful. She was managed conservatively, as surgical resection was deemed high risk. The spigots were removed 4 days later uneventfully. There was no recurrence of hemoptysis, and patient remained well during 1-month follow up.

Conclusions

The utmost priority in managing life-threatening hemoptysis is to prevent airway flooding. Endobronchial embolization with Endobronchial Watanabe Spigot is useful as a temporary measure before definitive therapy, or can itself be the main therapeutic player in the hemoptysis armament for high-risk patients.

Intrabronchial Infusion of Autologous Blood Plus Thrombin for Intractable Pneumothorax After Bronchial Occlusion Using Silicon Spigots: A Case Series of 9 Patients With Emphysema

Background:

Bronchial occlusion therapy using silicon spigots is effective for intractable pneumothorax. However, sometimes the pneumothorax is refractory to bronchial occlusion because of collateral ventilation. For such difficult pneumothoraces, we attempted an intrabronchial infusion of autologous blood plus thrombin to control collateral ventilation and stop air leaks.

Methods:

We performed bronchial occlusions using silicon spigots in patients with spontaneous pneumothorax secondary to emphysema and refractory to chest drainage, but which was inoperable owing to each patient’s poor surgical candidacy and poor overall health condition. When bronchial occlusion proved ineffective, we undertook intrabronchial infusion of autologous blood plus thrombin, 2 to 4 days after bronchial occlusion. A catheter was inserted into the subpleural area, through a gap between the silicon spigot and the bronchial wall, using a flexible bronchoscope under fluoroscopic guidance. Autologous blood, followed by a thrombin solution, was infused using the catheter. We repeated the same infusion a total of 4 to 6 times while changing the target bronchi. All interventions were performed under local anesthesia.

Results:

The subjects were 9 men, aged from 61 to 88 years, with smoking histories. Three patients also had interstitial pneumonia, and 6 patients had undergone pleurodesis in vain before bronchial occlusion. For 4of the 9 patients, autologous blood plus thrombin infusions successfully stopped air leaks, and in 3 patients, intrabronchial infusions and pleurodesis halted leaks altogether.

Conclusion:

Intrabronchial infusion of autologous blood plus thrombin was effective for intractable pneumothoraces that could not be clinically managed, even by bronchial occlusion using silicon spigots.

Effective treatment of empyema with bronchopleural fistula after esophagectomy by endobronchial embolization using endobronchial Watanabe Spigots

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In this case, we emphasized the value of Endobronchial Watanabe Spigot (EWS) use in bronchial embolization.

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Embolization with EWS is one of the first line options in conservative management of BPF after esophagectomy.

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We safely retried the 2nd endoboronchial embolization using the EWS.

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The patient with advanced esophageal cancer, clinical stage was cT3N1M0 stage IIIA was referred to our hospital. He underwent esophagectomy with video assisted thoracic surgery accompanied by reconstruction of the stomach through the posterior sternum after induction chemotherapy. The patient was in good condition and there was no recurrence.

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The patient was followed six months later, empyema was not occurred and the patient was in good general condition.

Introduction

Empyema and bronchopleural fistula are well known complications after thoracic surgery. We report a case of refractory air leakage of bronchopleural fistula in a patient with empyema that was successfully treated by endobronchial embolization using Endobronchial Watanabe Spigots (EWSs).

Presentation of case

A 71-year-old man underwent esophagectomy for primary esophageal cancer. A right empyema with bronchopleural fistula (BPF) developed four months after surgery. Right thoracic drainage tube was inserted. Although the empyema was treated by drainage and anti-biotics therapy, the air leakage was apparent. The chest computed tomography (CT) scan revealed that the bronchopleural fistula existed in the segment 6 and 10. Endobronchial embolization was performed to the responsible bronchus using EWSs. After the EWSs of middle and large sizes were inserted into the B⁶c and B¹⁰b + c, the air leakage was stopped. The thoracic tube of drainage was removed after endobronchial embolization. Complications due to the EWSs insertion were not observed, and the patient was discharged.

Discussion

The management of BPF has evolved over the years. Surgical approach is frequently needed to control the BPF, though endobronchial embolization is effective in closing the BPF in some patients. In our case, EWSs of middle and large size were useful to control air leakage. We safely retried the 2nd endoboronchial embolization using the EWS. The patient had no complication after insertion the EWS again.

Conclusion

Endobronchial embolization using EWSs was an effective treatment of an empyema with bronchopleural fistula after esophagectomy.

A Novel Technique for the Placement of Endobronchial Watanabe Spigots Into the Bronchus: Side-Grasping Method

BACKGROUND

Bronchial occlusion with an endobronchial Watanabe spigot (EWS) is effective for the management of persistent pulmonary air leaks; however, an optimal procedure for placing the spigot at the target bronchus remains debatable. The procedure most currently applied involves grasping the middle of the graspable part of the EWS with grasping forceps (conventional method). In this study, we assess a new technique, the side-grasping method, to maneuver the spigot into the target bronchus by using rotatable biopsy forceps to grasp the edge of the graspable part of the EWS. The aim of this study is to evaluate the effectiveness of this new technique for the simple placement of the EWS.

METHODS

To compare the number of bronchoscopists who were able to place the EWS correctly within 10 minutes, and the time needed to place each spigot for both methods into 4 canine bronchi.

RESULTS

More bronchoscopists correctly placed the EWS within 10 minutes using the side-grasping method compared with the conventional method (35/40 vs. 15/40, P<0.01). The total time needed to place spigots into all bronchi using the side-grasping method was 13±2.2 minutes versus 27.8±3.6 minutes using the conventional method (P<0.01).

CONCLUSION

The side-grasping method described in this study was a simple and effective technique for correctly placing an EWS spigot into the target bronchus.

A simple method of bronchial occlusion with silicone spigots (Endobronchial Watanabe Spigot; EWS®) using a curette

Background:

Bronchial occlusion with an Endobronchial Watanabe Spigot (EWS) has been shown to be useful in managing prolonged bronchopleural fistulas and intractable hemoptysis. EWS bronchial occlusion using a curette is less technically demanding. This retrospective study evaluated the clinical utility and simplicity of this method.

Methods:

A total of 18 consecutive patients (15 men, 3 women, aged 47–85 years) who underwent bronchial occlusion using an EWS from April 2012 to August 2014 were evaluated. The method involves sticking the tip of a curette into an EWS to the first joint, allowing it to be turned in any direction or at any angle. The time required to occlude the target bronchus was measured on routinely recorded digital videos. Other parameters evaluated included success rates, complications, and clinical outcomes.

Results:

Of the 18 patients, 11 underwent bronchial occlusion for intractable pneumothorax, 5 for postoperative bronchopleural fistula, two for intractable empyema, and one for hemoptysis. Each patient required 1–7 EWSs (median 4). Target bronchi included the right upper (n = 8), left upper (n = 5), right lower (n = 2), left lower (n = 2), and right middle (n = 1) bronchi. The success rate of EWS insertion into the target bronchus was 100%. Time per EWS occlusion ranged from 65–528 sec (median 158.5 sec). Of the 62 insertions, 36 (58.1%) were completed within 3 min, and 58 (93.5%) within 5 min. Successful outcomes were observed in 15 (83.3%) of the 18 patients.

Conclusions:

EWS bronchial occlusion using a curette is a simple method for managing intractable bronchopleural fistulas in daily clinical settings.

Endobronchial Watanabe Spigot Placement for a Secondary Pneumothorax

Although bevacizumab has several adverse effects, pneumothorax is rare. This is the first case of initial treatment using an Endobronchial Watanabe Spigot (EWS) for pneumothorax after bevacizumab-containing chemotherapy. A 56-year-old woman with recurrent breast cancer was treated with bevacizumab. Pneumothorax occurred 6 days after the last administration of bevacizumab. The pneumothorax failed to resolve after the chest tube drainage. This was because the bronchopleural fistula formed at the site of the subpleural metastatic lesion. Patient was in need of a surgical repair of the bronchopleural fistula, which could not be carried out due to the recent bevacizumab administration. After the insertion of the EWS, the air leak stopped immediately. A lobectomy was successfully performed for the recurrent pneumothorax and for the resection of the metastatic lung lesion; at a most appropriate duration since the chemotherapy. EWS is useful as the initial palliation of pneumothorax after the treatment with medication causing delayed wound healing.

Endoscopic bronchial occlusion with silicone spigots under virtual bronchoscopic navigation

A 68‐year‐old woman with interstitial lung disease related to dermatomyositis and systemic scleroderma was admitted to our hospital with fever and dyspnoea. Although the fever was reduced after antibiotic therapy, a left pneumothorax suddenly occurred on day 27 after admission. A continuous air leak persisted despite chest drainage with three tubes and repeated pleurodesis. Chest computed tomography (CT) images showed a cavitary lesion with a pinhole in the left upper division, which was suspected to be the affected lesion with the air leak. Virtual bronchoscopic navigation images were constructed from CT data. Bronchial occlusion with Endobronchial Watanabe Spigots (EWSs) was performed on day 52. Two medium‐sized EWSs were inserted into the left B1 + 2a and B1 + 2b, and the air leak stopped immediately. No procedure‐related adverse events occurred. All three chest tubes were successfully removed by day 60. This case demonstrates that virtual bronchoscopic navigation can improve bronchial occlusion procedures using EWSs.

Case report: Endobronchial valve placement for treatment of a persistent air leak

Demonstration of the therapeutic utility of endobronchial valves in elderly high-risk patients unsuitable for surgery http://ow.ly/Y7eEx.

Management Considerations for the Treatment of Idiopathic Massive Hemoptysis with Endobronchial Occlusion Combined with Bronchial Artery Embolization

This paper describes endobronchial embolization using silicone spigots (EESS), which is a potential treatment option for hemoptysis. A 63-year-old man with massive hemoptysis was treated with EESS to the left B(3), and bronchial artery embolization (BAE) was subsequently performed. However, the patient's hemosputum persisted and we performed another bronchoscopy. Bleeding was found from the left B(1+2). This was also treated with EESS. Subsequently, the patient achieved complete hemostasis with no complications for four months. EESS can prevent suffocation and can be a definitive treatment for achieving hemostasis in patients with recurrent hemoptysis after BAE.

Effective Management of Persistent Pneumothorax Using a Thopaz® Digital Drainage System Combined with an Endobronchial Watanabe Spigot

A 72-year-old man with salivary gland cancer and multiple pulmonary metastases suffering from intractable pneumothorax was transferred to our institution; he was inoperable because of a low pulmonary function. A chest tube had been placed more than a month prior to this admission. A digital drainage system was used for 24-h monitoring of air leaks (Thopaz®). Using the Thopaz® system, we performed endoscopic bronchial occlusion using an endobronchial Watanabe spigot (EWS) to reduce air leaks. Finally, the air leaks ceased, and the chest tube was removed five days after EWS placement. We herein report a case of persistent pneumothorax that was successfully treated by endoscopic bronchial EWS placement with the aid of a Thopaz® system.

Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema

A prolonged air leak caused by pulmonary tuberculosis is difficult to treat, and little is known about optimal treatment strategies. We herein report the case of a 60-year-old man who demonstrated tuberculous empyema with a fistula. An air leak from a tuberculous cavity in his left upper lobe persisted for approximately 4 months; surgical repair could not be performed due to a poor physical status and undernourishment. However, the air leak was successfully treated with endobronchial occlusion using two silicone spigots in left B3b and B4, without any adverse effects or aggravation of the infection.

Bronchial occlusion with Endobronchial Watanabe Spigots for massive hemoptysis in a patient with pulmonary Mycobacterium avium complex infection

The safety of occlusion with Endobronchial Watanabe Spigots (EWS) for the management of hemoptysis associated with chronic respiratory tract infection has not yet been established. A 57-year-old woman diagnosed as having pulmonary Mycobacterium avium complex (MAC) infection presented to our hospital with hemoptysis. She underwent bronchoscopy for bronchial occlusion with EWS, which resulted in the resolution of hemoptysis. Subsequently, she underwent bronchial artery embolization and then EWS were removed. During placement of EWS, no worsening of infection was observed. After removal of EWS, there was no recurrence of hemoptysis. Bronchial occlusion with EWS for hemoptysis associated with pulmonary MAC infection can be performed safely.

Endobronchial occlusion for massive hemoptysis with a guidewire-assisted custom-made silicone spigot: a new technique

Endobronchial Watanabe spigot is a device used to occlude bronchus for a variety of indications. It has been recently used for endobronchial occlusion for hemoptysis. However, its application is not always easy, particularly if the bleeding is originating from the upper lobes. To facilitate its placement, we developed a new technique using a guidewire and a custom-made spigot. We report a case of massive hemoptysis from a left lung cancer describing this new approach.

Pneumothorax triggered by the combination of gefitinib and amrubicin and treated with endobronchial silicone spigots

Pneumothorax is a rare complication in cancer chemotherapy. We report a case in which a male patient with advanced non-small cell lung cancer (NSCLC) developed repetitive pneumothorax after receiving a combination of the chemotherapeutic drugs gefitinib and amrubicin (GEF + AMR). Both episodes of pneumothorax occurred on the 3rd day of GEF + AMR administration. Tube thoracostomy was performed, but pulmonary air leaks persisted in the second pneumothorax. Whereas surgical intervention was not applicable because of poor respiratory reserve, the chest tube was successfully removed by endoscopic occlusion of bronchopleural fistula with endobronchial Watanabe spigots (EWSs), a type of silicone bronchial blocker.

Successful treatment of bronchial fistula after pulmonary lobectomy by endobronchial embolization using an endobronchial watanabe spigot

A bronchial fistula is one of the most serious complications that can occur following pulmonary lobectomy. We herein report a case of bronchial fistula that was successfully treated by endobronchial embolization using an Endobronchial Watanabe Spigot (EWS). A 72-year-old male underwent right lower lobectomy of the lung with nodal dissection for a pulmonary squamous cell carcinoma. A bronchial fistula developed 53 days after surgery. Tube drainage was performed, and air leakage was apparent. Under endoscopic observation, intrathoracic injection of indigo carmine revealed that a fistula existed at the peripheral site of the B²ai bronchus. After one EWS (small) was inserted into the B²a bronchus tightly using a bronchoscope, the air leakage was stopped. Pleurodesis was further carried out, the thoracostomy tube was subsequently removed, and the patient was discharged. Endobronchial embolization using an EWS is an option for the treatment of a bronchial fistula after pulmonary resection.

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.

Novel technique in managing bronchobiliary fistula in adults: Endobronchial embolization using silicone spigots in 2 cases

Bronchobiliary fistula (BBF) can complicate most hepatic pathologies. This is a challenging group of patients, especially when surgery is precluded. The bronchoscopic application of silicon spigots is a recognized technique for the treatment of massive hemoptysis and the management of patients with bronchopleural fistula following lung resection. Their role in the treatment of BBF has never been described. In this paper we report the successful embolization using silicon spigots in two patients with BBF secondary to malignant disease, when all surgical options were exhausted.

Efficacy and long-term clinical outcome of bronchial occlusion with endobronchial Watanabe spigots for persistent air leaks

BACKGROUND

We reviewed our clinical experience and examined the efficacy and long-term outcome of bronchial occlusion with endobronchial Watanabe spigots (EWSs).

METHODS

We retrospectively reviewed the clinical charts of patients who had undergone endoscopic bronchial occlusion with EWSs between July 2002 and July 2004. The affected bronchi were identified by chest computed tomography, pleurography, and balloon occlusion test.

RESULTS

Of the 21 patients, 18 had underlying pulmonary complications, including chronic obstructive lung disease (n=14), cancer (n=4), pneumoconiosis (n=3), and pneumonia (n=1). Six (29%) achieved complete resolution and 12 (57%) experienced a reduction in air leaks after the first EWS insertion. Of the 12 patients with reduced air leaks, 10 subsequently underwent chemical pleurodesis and 5 (24%) achieved complete resolution after the procedure. A second EWS insertion procedure was performed for 8 patients: 2 achieved complete resolution and 5 achieved a further reduction in air leaks with complete resolution after chemical pleurodesis. Eighteen of the 21 patients were followed up at an outpatient clinic after discharge: 13 for more than 12 months and 4 for more than 84 months. During the follow-up period, most patients did not show any obvious pulmonary complications.

CONCLUSIONS

We showed that bronchial occlusion with EWSs was effective in stopping or reducing air leaks and that 86% of our patients finally achieved complete resolution, some when the occlusion was combined with chemical pleurodesis. The rate of complications was acceptable, even after long-term placement.

Bronchoscopic treatment of complex persistent air leaks with endobronchial one-way valves

We reported a case series including 5 patients with persistent air-leaks refractory to standard treatment. All patients were unfit for surgery for the presence of co-morbidities and/or severe respiratory failure due to underlying lung diseases. They were successfully treated with bronchoscopic placement of endobronchial one-way valves. Air-leaks stopped in the first 24 h after the procedure in three patients and 3 and 5 days later, respectively, in the remaining two. No complications were observed and follow-up was uneventful in all patients but one died 25 days after the procedure for systemic sepsis due to peritonis. Patients with important, refractory air leaks having clinical repercussions and unfit for surgery should be early reviewed for bronchoscopic valves treatment.

Successful closure of bronchopleural fistula with Xeroform dressing

Bronchopleural fistula (BPF) is a communication between the pleural space and the bronchial tree, and is associated with significant morbidity and mortality. Treatment options for BPF include surgical closure and medical therapy. In an unstable patient, invasive surgical intervention is not an option. In this article, we report the case of a 61-year-old man who developed pneumothorax with a large BPF after a bronchoscopic resection of a malignant endobronchial lesion. We inserted a piece of 1.5×1.5-cm Xeroform dressing to seal the massive air leak with successful closure of the BPF. To our knowledge, this is the first report of successful closure of a massive BPF with Xeroform dressing in an acutely decompensating patient.

Treatment of intractable pneumothorax with emphysema using endobronchial watanabe spigots

Prolonged air leakage is a major cause of morbidity in pneumothorax. When conservative management is not effective, surgery should be performed. However, surgery is not appropriate in patients with low pulmonary function. In these patients, occlusion of the airway with endobronchial blockers may be attempted under bronchoscopy. We treated two patients with prolonged air leakage using endobronchial Watanabe spigots under fibrobronchoscopy.

Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring

BACKGROUND

Prolonged alveolar-pleural air leaks are associated with increased morbidity and mortality. Endoscopic valve therapy has been recently introduced as a potential less invasive treatment option. We aimed at quantifying the effects of valve therapy on air leak flow and clinical outcomes in patients with prolonged air leaks.

METHODS

We report on a series of 16 patients with high comorbidity and evidence of continuous air leak flow in whom chest tubes remained in place for at least 7 days. After identification of the source of the air leak by use of the balloon occlusion technique, endobronchial one-way valves were implanted. Digital chest tube monitoring was used to assess air leak flow before, during, and after valve implantation until chest tube removal.

RESULTS

The source of the air leak was endoscopically identified in 13 patients (81%). After valve implantation, air leak flow decreased significantly from 871±551 mL/min to 61±72 mL/min immediately after the intervention (p<0.001). The mean duration of chest tube drainage was 18±8 days before and 9±6 days after the intervention (p<0.01). Ten patients were considered responders, and 3 patients were nonresponders. Responders demonstrated consistent air leak flow levels below 100 mL/min until chest tube removal. Long-term follow-up was available for 9 patients. No adverse events related to the valve implants were reported at follow-up. Seven patients underwent valve removal without any further complications.

CONCLUSIONS

Endoscopic implantation of one-way valves leads to a significant reduction in air leakage flow and may thus be a valuable treatment option in patients with prolonged air leakage.