Bilateral Endobronchial Valves: An Option for Severe Bilateral Persistent Air Leak

Abstract

Introduction: Bronchopleural fistulas (BPF) with persistent air leak (PAL) are associated with significant morbidity, including longer ICU and hospital stays and increased incidence of pneumonia. Some PAL are managed conservatively with chest tube placement and ventilator adjustments, while some require chemical/blood patch pleurodesis or surgical intervention. Endobronchial valves (EBVs) and intrabronchial valves (IBVs) have been proposed as nonsurgical options for PAL and have been effective in select cases. This case reports the bilateral placement of IBVs to address large bilateral PAL in a patient with e-cigarette or vaping product use-induced lung injury (EVALI) requiring extracorporeal membrane oxygenation (ECMO). Case Description: Patient is a 19-yearold male with history of marijuana abuse (smoking and “heavy” vaping) who presented with progressive shortness of breath. Imaging demonstrated extensive bilateral alveolar consolidations with air bronchograms and groundglass opacities with areas of reticulation and cystic changes. Respiratory viral PCR testing including COVID-19 were negative, and patient was initiated on broad-spectrum antibiotics and high-dose steroids for presumed EVALI. He was intubated due to hypoxic respiratory failure and developed bilateral pneumothoraces requiring placement of bilateral large-bore thoracostomy tubes. Large bilateral PALs with residual pneumothoraces did not resolve after placement of additional bilateral thoracostomy tubes. Venovenous ECMO was initiated due to hypercapnia and hypoxia on maximal ventilator settings. To promote pleurodesis with continued large bilateral PAL, Spiration IBVs were deployed to RB 1, RB 2, RB 3, LB 1-3, and LB 4-5. Blood patch pleurodesis was also performed bilaterally. IBVs at RB 3 and LB 4-5 were subsequently found to have migrated and were replaced. The bilateral PALs nearly resolved with these interventions, and ventilator air leak diminished. Patient ultimately developed diffuse alveolar hemorrhage and was transferred on ECMO for lung transplant evaluation due to severe irreversible pulmonary parenchymal disease. Discussion: Endobronchial and intrabronchial valve use for treatment of bronchopleural fistulas has been reported in the literature since 2002, but have generally been used for postoperative PAL or spontaneous pneumothorax with PAL. This patient had severe parenchymal lung disease secondary to EVALI and developed bilateral pneumothoraces with large PALs while ventilated, requiring ECMO for adequate oxygenation. Spiration IBVs were deployed to the right upper lobe and left upper lobe/lingula with near resolution of air leaks. Although this patient's severe parenchymal disease did not permit discontinuation of ECMO despite improved ventilation, the use of endobronchial and intrabronchial valves provides a less invasive intervention for persistent BPF in the unstable patient.