LEFT UPPER LOBE ATELECTASIS WITH PNEUMOTHORAX THREE YEARS AFTER BRONCHOSCOPIC LUNG VOLUME REDUCTION SURGERY

Abstract

TOPIC: Procedures TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bronchoscopic lung volume reduction surgery (BLVRS) is a minimally invasive treatment option for severe emphysema with hyperinflation and air trapping. The one-way valves are designed to induce lobar atelectasis. The most common complication is pneumothorax, which usually develops within 72 hours after BLVRS. We present a case of delayed atelectasis with a large left pneumothorax, 3 years after left upper lobe (LUL) BLVRS with three Zypher® valves. CASE PRESENTATION: A 64 year-old-female with a past medical history of severe emphysema on oxygen presented to a local hospital with dyspnea. Chest radiography revealed a large left pneumothorax. CT chest also showed complete LUL atelectasis. Of note in 2018, the patient underwent LUL BLVRS without interval development of atelectasis. Given the new findings, a chest tube was placed. She was transferred to our hospital for interventional pulmonary consultation after 6 days of conservative management for persistent air leak. Bronchoscopy revealed three Zypher® valves occluding the LUL and lingula. Balloon occlusion of the left main stem resulted in air leak cessation. Subsegmental occlusion of the left lower lobe superior segment revealed no change, but there was significant air leak reduction after anteromedial segment occlusion. A 5 mm Spiration® valve was then deployed, causing the air leak in the pleurovac to switch from continuous to intermittent. Over the next 48 hours, the air leak resolved with near resolution of the pneumothorax. Chest tube was removed, and the patient was discharged home after 24 hour observation. DISCUSSION: BLVRS is a minimally invasive treatment option for emphysema with hyperinflation and air trapping. Endobronchial valves are placed in a target lobe after fissure integrity confirmation. The goal is to cause deflation and subsequent atelectasis of the target lobe. However, 30-40% of patient do not develop immediate lobar atelectasis. The exact mechanism behind such a delay is not clear. It has been postulated by Nabil Jarad, et al., that a breach in fissure integrity prior to valve placement could account for lack of immediate atelectasis. Alternatively, there may have been a paravalvular leak accounting for the lack of response initially. We present a case of delayed left upper lobar atelectasis with pneumothorax, 3 years after BLVRS with appropriately placed Zypher® valves. The patient was managed with balloon occlusion bronchoscopy with Spiration® valve placement instead of Zypher® valve removal. CONCLUSIONS: The possibility of delayed lobar atelectasis with pneumothorax after BLVRS is something that interventionists should consider discussing with patients who do not develop lobar atelectasis after BLVRS with appropriately placed endobronchial valves. The risk of pneumothorax has been described to be the highest in the first 72 hours post-procedure, but as seen with our patient, it can still happen after 3 years. REFERENCE #1: Creber P, Bendall O, Jarad N. Delayed Response to Endobronchial Emphysema Valve Insertion. Clin Respirat Med. 2018; 1(1): 1003. REFERENCE #2: Franzen D, Straub G, Freitag L. Complications after bronchoscopic lung volume reduction. J Thorac Dis. 2018;10(Suppl 23):S2811-S2815. doi:10.21037/jtd.2018.06.66. REFERENCE #3: Shah PL, Herth FJF. Current status of bronchoscopic lung volume reduction with endobronchial valvesThorax 2014;69:280-286. DISCLOSURES: No relevant relationships by Muhammad Arif, source=Web Response No relevant relationships by MAYKEL IRANDOST, source=Web Response No relevant relationships by Abid Khokar, source=Web Response No relevant relationships by Jonathan Munoz, source=Web Response no disclosure submitted for Ali Saeed; No relevant relationships by Andrew Talon, source=Web Response