Endobronchial Valve Insertion Research Articles

Lung volume reduction surgery: a micro-costing analysis from a national tertiary referral Centre.

Lung volume reduction surgery (LVRS) is a clinically effective palliation procedure for patients with chronic obstructive pulmonary disease (COPD). LVRS has recently been commissioned by the NHS England. In this study, a costing model was developed to analyse cost and resource implications of different LVRS procedures. Three pathways were defined by their surgical procedures: bronchoscopic endobronchial valve insertion (EBV-LVRS), video assisted (VATS-LVRS), and robotic assisted LVRS (RATS-LVRS). The costing model considered use of hospital resources from the LVRS decision until 90-days after hospital admission. The model was calibrated with data obtained from an observational study, electronic health records, and expert opinion. Unit costs were obtained from the hospital finance department and reported in 2021-Euros. VATS-LVRS was associated with the lowest cost at €12,896 per patient. This compares to the costs of EBV-LVRS at €15,598 per patient and €13,305 per patient for RATS-LVRS. A large component of EBV-LVRS costs were accrued secondary to complications, including revision EBV-LVRS. This study presents a comprehensive model framework for the analysis of hospital-related resource use and costs for the three surgical modalities. In the future, service commissioning agencies, hospital management, and clinicians can use this framework to determine their modifiable resource use (composition of surgical teams, use of staff and consumables, planned length of stay, and revision rates for EBV-LVRS) and to assess the potential cost implications of changes in these parameters.

Practices and perspectives on advanced diagnostic and interventional bronchoscopy among pediatric pulmonologists in the United States.

Advanced diagnostic bronchoscopy includes endobronchial ultrasound (EBUS) guided transbronchial lung and lymph node biopsies, CT navigation and robotic bronchoscopy. Interventional bronchoscopy refers to procedures performed for therapeutic purposes such as balloon dilation of the airway, tissue debulking, cryotherapy, removal of foreign bodies and insertion of endobronchial valves [1]. For adult patients, these procedures are standard of care [2, 3]. Despite a lack of formalized training, there are numerous case reports and case series describing the use of advanced diagnostic and interventional bronchoscopy techniques in children. The safety and feasibility of EBUS-TBNA, cryotherapy techniques, endobronchial valves among other techniques have been demonstrated in these publications [1, 4-9]. We sought to better understand the current practices and perspectives on interventional and advanced bronchoscopy among pediatric pulmonologists through surveys sent to pediatric teaching hospitals across the United States. We received 43 responses representing 28 programs from 25 states. The highest bronchoscopy procedure volume occurred in the 0-5 years age group. Among our respondents, 31% self-identified as a pediatric interventional/advanced bronchoscopist. 79% believe that advanced and interventional training is feasible in pediatric pulmonology and 77% believe it should be offered to pediatric pulmonary fellows. This is the first study to characterize current practices and perspectives regarding advanced diagnostic and interventional bronchoscopy procedures among pediatric pulmonologists in the United States. Pediatric interventional pulmonology (IP) is in its infancy and its beginnings echo those of the adult IP where only certain centers were performing these procedures.

Endobronchial valve use in COVID-19 related pneumothorax and persistent air leak.

Pneumothoraces may occur rarely in coronavirus (COVID-19) patients, often resulting from a combination of fibrotic parenchymal changes and prolonged high-pressure ventilation. Very few studies have been published describing the management of pneumothorax in the novel COVID-19 pneumonia patients. Although chest drain insertion represents the first line of treatment, a persistent pneumothorax and air leak requiring intervention could be managed by a thoracoscopic procedure or, as is the case here, by endobronchial valve insertion. Endobronchial valve insertion is a minimally invasive technique that provides a treatment option in patients with severe parenchymal COVID-19 related lung disease. As far as the authors are aware this is the first report of the use of endobronchial valves in a COVID-19 patient.

“All things must pass” - Cutaneous migration of an endobronchial valve

SummaryThe Zephyr (PulmonX Inc., Redwood, CA) endobronchial valve (EBV), predominantly designed for lung volume reduction in emphysema, can also be used to close a spontaneous or post-operative prolonged air leak (PAL). We describe a previously unreported complication of cutaneous migration of an EBV, inserted for management of a PAL from a postoperative bronchopleural fistula (BPF), in a 62-year-old male following a right upper lobe posterior-apical (S1,2) segmentectomy. His PAL resulted in a chronic empyema which failed to respond to surgical debridement, anterior cavernostomy and pectoral myoplasty. Bronchoscopic closure of the air leak by EBV insertion resulted in clinical improvement but there was a residual chronic wound sinus through which the patient reported protrusion of a foreign body that was causing irritation. It was the EBV. We hypothesise that the BPF healed beneath the EBV causing it to dislodge but its route to the skin remains a mystery.

Spontaneous alveolo-pleural fistula in a case of COVID-19 pneumonia-challenges and solutions: case report

COVID-19 pneumonia has demonstrated a wide spectrum of clinical presentations that have yet to be completely uncovered. As this pandemic progresses, uncommon presentations of this disease have come into light. Development of broncho/alveolo-pleural fistula in a patient with COVID-19 pneumonia is a rare phenomenon with only 4 cases reported in literature till date. A 61-year-old gentleman presented to the emergency department with fever, cough, and shortness of breath. His initial chest X-ray was suggestive of a viral pneumonia that was later confirmed to be due to COVID-19. The patient was put on non-invasive ventilator support and treated with empirical antibiotics, glucocorticoids, anti-viral medications and convalescent plasma therapy. Four weeks into the patient’s hospital course, his vital parameters suddenly deteriorated with a subsequent chest X-ray showing a tension pneumothorax, for which a chest tube insertion was done. However, when the air leak did not resolve by the 3rd day, a chest computed tomography (CT) was planned which showed a spontaneous alveolo-pleural fistula (APF). The patient was managed with conservative treatment using negative suction applied to an underwater seal, had his chest tube removed 10 days later and was discharged subsequently. Spontaneous fistulisation between broncho-alveolar tree and pleura can occur rarely in patients with COVID-19 pneumonia and can be managed using underwater seal with negative suction, insertion of endobronchial valves or surgical closure, and needs to be individualised.

Persistent air leak management in critically ill patients

Persistent air leak (PAL) is a challenging clinical entity, particularly in the setting of critical illness. It is a significant cause of morbidity, health care expenditure, and resource utilization. Data on its prevalence in the critically ill patient population are limited. Unique patient factors often necessitate an individualized approach. Guidelines on this subject are antiquated and do not specially address patients on mechanical ventilation. Critically ill patients may not be able to tolerate surgical intervention. Treatment in this population relies upon lung protective ventilation, various anecdotal modalities, chemical pleurodesis, autologous blood patching, and bronchoscopic insertion of endobronchial valves. Ventilation strategies center on rapid weaning and reduction of airway pressures. Anecdotal methods include implantable devices and chemical agents. Data on these modalities are limited to case reports. None have United States Food and Drug Administration (FDA) approval. The Spiration Valve System is FDA approved as a Humanitarian Device Exemption. Data on endobronchial valves are based on large case series, and only one small case series has focused exclusively on critically ill patients. The majority of valves in critically ill mechanically ventilated patients are used for non-FDA approved indications. Updated guidelines are desperately needed to ensure a standardized approach to this common clinical situation.

Reduction of COPD Hyperinflation by Endobronchial Valves Improves Intercostal Muscle Morphology on Ultrasound.

Background and ObjectivesParasternal intercostal ultrasound morphology reflects spirometric COPD severity. Whether this relates to the systemic nature of COPD or occurs in response to hyperinflation is unknown. We aimed to assess changes in ultrasound parasternal intercostal muscle quantity and quality (echogenicity) in response to relief of hyperinflation. We hypothesised that reduction in hyperinflation following endobronchial valve (EBV) insertion would increase ultrasound parasternal thickness and decrease echogenicity.MethodsIn this prospective cohort study, eight patients with severe COPD underwent evaluation of health-related quality of life, lung function, and sonographic thickness of 2nd parasternal intercostal muscles and diaphragm thickness, both before and after EBV insertion. Relationships between physiological and radiographic lung volumes, quality of life and ultrasound parameters were determined.ResultsBaseline FEV1 was 1.02L (SD 0.37) and residual volume (RV) was 202% predicted (SD 41%). Median SGRQ was 63.26 (range 20–70.6). Change in RV (−0.51 ± 0.9L) following EBV-insertion showed a strong negative correlation with change in parasternal thickness (r = −0.883) ipsilateral to EBV insertion, as did change in target lobe volume (−0.89 ± 0.6L) (r = −0.771). Parasternal muscle echogenicity, diaphragm thickness and diaphragm excursion did not significantly change.ConclusionsDynamic changes in intercostal muscle thickness on ultrasound measurement occur in response to relief of hyperinflation. We demonstrate linear relationships between intercostal thickness and change in hyperinflation following endobronchial valve insertion. This demonstrates the deleterious effect of hyperinflation on intrinsic inspiratory muscles and provides an additional mechanism for symptomatic response to EBVs.

Patient-directed Volume Reduction for Emphysema: Sequential Surgical and Endobronchial Techniques

Lung volume reduction (LVR) surgery has traditionally been performed as a 1-stage bilateral procedure or staged at a predetermined interval. However to maximize the overall benefit we have allowed the patient to determine the timing of further interventions and have added endobronchial LVR into the protocol. We have reviewed the long-term outcome. Three hundred thirty-one LVR procedures were performed on 254 patients (median age, 61 years [range, 23-79]) with baseline predicted lung function of (mean ± SD) forced expiratory volume in 1 second 28% ± 11% and residual volume 253% ± 53%. The initial procedure was by video-assisted thoracoscopic surgery in 236 patients (unilateral, 227; bilateral, 9), by open surgery in 5, and by endobronchial valve insertion in 13. Sixty-four patients received a second and 13 a third LVR procedure. The median time interval between first and third stage was 5.8 years (range, 1.9-10) RESULTS: In the subgroup of patients who underwent staged procedures there was a significant improvement in predicted forced expiratory volume in 1 second from 28% at baseline to 34% up to 6 years. There was sustained reduction in static lung volumes up to 8 years: Predicted residual volume remained reduced from 259% to 189%. There were sustained improvements over baseline in health status: EuroQol-5D improved from 50 ± 26 to 62 ± 23 (P < .01) for up to 5 years and the Short Form 36-item questionnaire for up to 9 years. Overall 30-day mortality was 3%. Median survival was 5.6 years (95% confidence interval, 4.7-6.9). A program of staged unilateral procedures of LVR has resulted in sustained benefits for up to 9 years in physiology and health status.

Endoscopic one-way endobronchial valves in the treatment of persistent air leak with empyema

Background: Persistent air leak complicated by empyema is a life-threatening condition especially in patients with pulmonary emphysema. Surgical approaches are often disappointing and demolitive surgery is often needed. Endobronchial valves have been successfully applied for persistent air leak but their use in case of concurrent empyema has been reported in very few cases. We present a case series of six consecutive patients with persistent air leak and empyema, successfully treated by endobronchial valves. Methods: Bronchoscopic procedures included preliminary identification of the area of air leakage by bronchial occlusion using a balloon catheter. The nitinol and silicon valves (Pulmonx ® ) were inserted by means of flexible bronchoscopy in all cases. Chest drain was removed after negativity of microbiological essay from pleural liquid. Results: Four patients had severe emphysema with chronic respiratory failure and smoking history. One patient was affected by rheumatoid arthritis and one had chronic heart failure and diabetes. Four cases were postoperative air leakage after lung resection and two cases were due persistent spontaneous pneumothorax. Empyema was mainly due to Acinetobacter baumannii or Pseudomonas aeruginosa or staphylococcus aureus. Procedures were successful in every case. Air-leaks stopped in the first 24 hours after procedure in two patients and within 7 days in the remaining cases. All patients were discharged within 3 weeks without complications. Conclusions: Insertion of endobronchial valves is a safe and effective method for treating persistent air leak even during empyema in selected cases and especially for patient unfit for surgery.

Anaesthetic management for endobronchial valve insertion: lessons learned from a single centre retrospective series and a literature review

BackgroundEndoscopic lung volume reduction using one or more endobronchial valves is a treatment option for a select group of patients with severe emphysema. Patients presenting for this procedure pose various challenges to the anaesthetist; in addition to their lung condition, they are often elderly with multiple comorbidities. The procedure is usually performed outside the operating room. Monitored anaesthesia care with intravenous sedation, and general anaesthesia with an endotracheal tube have both been described for these procedures, aiming for adequate ventilation and haemodynamic stability.MethodsWe present our experience on 20 of these procedures in relation to the anaesthetic techniques employed and discuss the perioperative challenges involved in managing these cases.ResultsTwenty one planned endobronchial valve insertion procedures were identified on 18 patients. There were ten cases of monitored anaesthesia care with sedation and 10 cases which used general anaesthesia with an endotracheal tube. Two have been excluded; one had features of anaphylaxis and the procedure was abandoned, and the other required conversion from monitored anaesthesia care to general anaesthesia with endotracheal tube.ConclusionsBoth monitored anaesthesia care with sedation and general anaesthesia with endotracheal tube were well tolerated during endobronchial valve insertion procedures. General anaesthesia with endotracheal tube may offer better interventional conditions, patient comfort and reduced anaesthetic time.

The accuracy of computed tomography to predict completeness of pulmonary fissures. A prospective study.

Endobronchial valves are a potential alternative to lung volume reduction surgery for advanced emphysema. The greatest improvements in pulmonary function are seen in patients with complete pulmonary fissures, as determined by computed tomography (CT). However, the accuracy of CT to predict completeness of pulmonary fissures has not been compared with the reference standard of direct observation during thoracic surgery. To determine the accuracy of CT scans to predict completeness of pulmonary fissures. We conducted a double-blind, prospective trial in which completeness of pulmonary fissures was evaluated by direct observation during thoracic surgery. Preoperative CT scans were independently reviewed by two dedicated thoracic radiologists and completeness of the fissures was recorded and compared with intraoperative findings. The fissures of 46 patients were evaluated. The positive predictive value of CT scan to detect a complete fissure was 100% for the right major fissure and 75% for the left fissure, but only 33% for the right minor fissure. CT scans had a negative predictive value of 29% in evaluation of the right major fissure. CT scans overestimate completeness of the right minor fissure and underestimate completeness of the right major fissure. These findings may have implications for the use of CT scans to select patients for endobronchial valve insertion.

Endobronchial Valves in the Treatment of Persistent Air Leak, an Alternative to Surgery

IntroductionPersistent 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 analyze their efficacy in a series of patients with persistent air leaks. Materials and methodsThe 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. ResultsFrom 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. ConclusionsInsertion of endobronchial valves is a safe and effective method for treating persistent air leaks, and a valid alternative to surgery.

Válvulas endobronquiales para el tratamiento de la fuga aérea persistente, una alternativa al tratamiento quirúrgico

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

Pieces to the Puzzle of Endobronchial Valve Insertion for Emphysema

Pieces to the Puzzle of Endobronchial Valve Insertion for Emphysema

Year in review 2010: Interstitial lung diseases, acute lung injury, sleep, physiology, imaging, bronchoscopic intervention and lung cancer

Year in review 2010: Interstitial lung diseases, acute lung injury, sleep, physiology, imaging, bronchoscopic intervention and lung cancer

Effect of unilateral endobronchial valve insertion on pulmonary ventilation and perfusion: A pilot study

The effects of bronchoscopic lung volume reduction (BLVR) on pulmonary ventilation and perfusion are incompletely understood. In this pilot trial, we investigated serial changes in regional ventilation and perfusion following unilateral endobronchial valve placement in COPD patients with heterogeneous emphysema. At baseline and at days 30 and 90 following BLVR, subjects underwent lung function, 6MWD and St George's Respiratory Questionnaire. Ventilation and perfusion scintigraphy were performed to quantitate and serially compare regional differences. Six out of eight subjects completed the study; all had endobronchial valves targeting their left upper lobe. At day 90 post-BLVR, there was a trend towards an increase in FEV(1) and a mean reduction in St George's Respiratory Questionnaire score of nine units. In the targeted left upper zone there was reduced ventilation and perfusion. Ventilation and perfusion to the right lung; and specifically the right lower zone, significantly increased. There appears to be redistribution of ventilation and perfusion to the contralateral lung following endobronchial valve placement. This may be of importance when assessing patients for unilateral BLVR. Selecting patients with heterogeneous disease is emphasized, taking into consideration not just comparison between upper and lower lobes, but between left and right lungs. A larger trial is currently underway, guided by these findings.

MDCT assessment of lung volume in patients undergoing bronchial stenting for treatment of pulmonary emphysema: correlation with respiratory tests and personal experience

The aid of this study was to evaluate lung volume reduction with multidetector-row computed tomography (MDCT) in patients with emphysema who have undergone endobronchial valve placement. Nine patients with emphysema were studied by low-dose chest MDCT (64-slice Somatom Sensation Cardiac, Siemens) with a collimation of 64 x 0.6 mm and a slice thickness of 1 mm. After treatment, MDCT scans were repeated at 7 and 30 days. A single observer calculated the volume of the treated lobe and of both lungs on a dedicated console. Volume calculations were then compared with the results of lung function tests. Four patients in whom MDCT showed severe emphysema of the right upper lobe (RUL) were selected for endobronchial valve insertion. Volume assessment at 30 days showed a 29% reduction in RUL volume in patient A, a 15% reduction in patient B, a <1% reduction in patient C and a 30% reduction in patient D. Correlation with lung function tests confirmed a major reduction of forced expiratory volume in 1 s (FEV(1)) and vital capacity (VC) and improved walking test results after 7 and 30 days. In patients undergoing endobronchial valve placement, MDCT with dedicated software allows for a better evaluation of volume reduction of a single lobe and of the whole lung.

Bronchoscopic volume reduction with valve implants in patients with severe emphysema.

Eight patients with severe emphysema entered a pilot study of unilateral volume reduction by endobronchial valve insertion. Five patients had emphysema judged too severe for volume reduction surgery and three refused the operation. After valve insertions, the median forced expiratory volume in 1 s (FEV1) increased from 0.79 L (range 0.61-1.07) to 1.06 L (0.75-1.22) (difference 34%, p=0.028) and the median diffusing capacity (TL(CO)) increased from 3.05 mL/min/mm Hg (2.35-4.71) to 3.92 mL/min/mm Hg (2.89-5.40) (difference 29%, p=0.017). CT scans showed a substantial reduction in regional volume in four of the eight patients. Two patients developed a transient pneumothorax (one requiring drainage) but we recorded no other important adverse effects during follow-up. Lung-volume reduction can be achieved with unilateral bronchoscopically placed valve implants in patients with severe emphysema with acceptable short-term safety and worthwhile functional benefits.