Intrabronchial Valves Research Articles

Bronchial Valves for Persistent Air Leak: A Systematic Review and Meta-analysis.

Patients with persistent air leak (PAL) pose a therapeutic challenge to physicians, with prolonged hospital stays and high morbidity. There is little evidence on the efficacy and safety of bronchial valves (BV) for PAL. We systematically searched the PubMed and Embase databases to identify studies evaluating the efficacy and safety of BV for PAL. We calculated the success rate (complete resolution of air leak or removal of intercostal chest drain after bronchial valve placement and requiring no further procedures) of BV for PAL in individual studies. We pooled the data using a random-effects model and examined the factors influencing the success rate using multivariable meta-regression. We analyzed 28 observational studies (2472 participants). The pooled success rate of bronchial valves in PAL was 82% (95% confidence intervals, 75 to 88; 95% prediction intervals, 64 to 92). We found a higher success rate in studies using intrabronchial valves versus endobronchial valves (84% vs. 72%) and in studies with more than 50 subjects (93% vs. 77%). However, none of the factors influenced the success rate of multivariable meta-regression. The overall complication rate was 9.1% (48/527). Granulation tissue was the most common complication reported followed by valve migration or expectoration and hypoxemia. Bronchial valves are an effective and safe option for treating PAL. However, the analysis is limited by the availability of only observational data.

Off-label use of intrabronchial valves for persistent air leak is safe and effective: a retrospective case analysis.

Persistent air leak (PAL) is a challenging clinical problem associated with prolonged hospital stay and increased morbidity. Historically, treatment options were limited to thoracostomy tube drainage, pleurodesis, and surgical repair. The development of one-way airway valves has represented a paradigm shift in PAL management. We present our experience using intrabronchial valves (IBVs) for PAL management looking at both on-label (post-thoracic surgery) and off-label (all other) indications. We performed a retrospective review of our single-center experience. Data collected included demographics, primary pathology leading to PAL, comorbidities, time to chest tube removal, complications, mortality, need for any additional procedure, and time to IBV removal. During the study period, 15 patients underwent IBV insertion for PAL. The on-label cohort contained three patients (post lobectomy or segmentectomy). The off-label cohort had 12 patients (6 empyema, 4 secondary spontaneous pneumothorax, 1 penetrating trauma, and 1 post percutaneous lung nodule biopsy). In the on-label cohort, chest tube was removed after a mean duration of 4.0±1.0 days for all patients. In the off-label cohort, 83.3% (10/12) had chest tube removal 16.2±5.7 days (P=0.396) after IBV placement. One patient developed hypoxic respiratory failure shortly after IBV insertion, necessitating removal of 2 out of 5 valves. IBVs are a minimally invasive, well tolerated treatment modality for patients with PAL and a viable alternative to invasive surgical interventions. Procedure or valve-related complications are uncommon. Valves can be removed and do not preclude surgical intervention. Updated guidelines are necessary to formalize PAL management.

Clinical outcomes and quantitative CT analysis after bronchoscopic lung volume reduction using valves for advanced emphysema

BackgroundBronchoscopic lung volume reduction (BLVR) using Zephyr endobronchial valve (EBV) and intrabronchial valve (IBV) has been shown to improve lung function and exercise capacity in severe emphysema. However, changes in airway structures and whether these are related to the clinical improvements remain unclear.MethodsA retrospective study was performed on patients treated with BLVR. We compared changes in 2nd-, 3rd-, and 4th-generation bronchial structures after therapy, including wall thickness (WT), percentage of wall thickness (WT%), intraluminal area (LA), wall area (WA), and WA%. Responder and non-responder subgroup analysis according to minimum clinically important difference (MCID) which was defined as an improvement of 15% in forced expiratory volume in 1 s (FEV1) and 26 m in 6 min walk distance (6MWD) was conducted.ResultsOf the 19 patients, 11 were treated with EBV and 8 with IBV. In ipsilateral non-target lobes, WT% decreased significantly in 3rd-generation bronchi at 1 month, 3, and 6 months, as well as their WA% at 1 month and 6 months. Non-responders, who were unable to achieve MCID, showed no consistent bronchial wall changes. And their LA of 3rd-generation bronchi decreased especially at 1 month. After BLVR, the target lobe volume decreased significantly until 12 months of follow-up. The volume of ipsilateral lobes could increase correspondingly and achieve the best improvements at 6 months. The contralateral lung volume showed slight amelioration but there was no statistical significance.ConclusionsBoth airway structures and lung volumes showed changes after BLVR. The 3rd- and 4th-bronchial walls tend to be thinner, which were consistent with clinical improvements. Further studies are needed to prove this conclusion and find detect potential mechanics.

Utility of Functional Pneumonectomy by Using Intrabronchial Valves: First Case Series and Single Center Experience.

Intrabronchial valves are approved for bronchoscopic lung volume reduction in chronic obstructive pulmonary disease patients and used for prolonged air leak. There is no data on bronchoscopic functional pneumonectomy (BFP) when treating patients with persistent air leak (PAL) or for lung volume reduction purposes. In this observational study, 10 consecutive patients who failed to improve with traditional therapies were assessed after they underwent BFP for PAL or lung volume reduction. Ten patients underwent 17 valve placement procedures; 82 valves were placed (median: 8; range: 5 to 12). BFP was performed in 1 single lung transplant patient with hyperinflation of native lung compromising lung function. The rest of the patients had prolonged air leak because of various reasons; spontaneous (n=7) and postoperative (n=2). Pneumonia was the only procedure-related complication seen in 1 patient. Of patients with prolonged air leak with chest tubes (n=9), all had successful chest tube removal (median of 7 days; range: 3 to 21 d). The valves were removed within 6 weeks of chest tube removal in 6 patients. Prebronchoscopic and post-BFP actual forced expiratory volume in first second values in 2 transplant patients. PAL usually occurs in patients with severe underlying lung condition or after surgery. Management of PAL can be challenging despite pleurodesis (medical or surgical). BFP offers a minimally invasive management option.

BRONCHOPLEURAL FISTULA? ENDOBRONCHIAL VALVES TO THE RESCUE

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Bronchopleural fistula (BPF) is a sinus tract between the main stem, lobar, or segmental bronchus and the pleural space. Most commonly seen as a complication of lung resection surgery with morbidity ranging from 25%-71%. Treatment of BPF primarily is surgical closure but might but bronchoscopic interventions can be considered in certain cases. Here we present a case of endobronchial valves (EBVs) being used as a bridge to surgery. CASE PRESENTATION: A 60-year-old man presented muscle weakness, anterior mediastinal mass and respiratory failure requiring intubation. Diagnosis of myasthenic crisis was made and he underwent three rounds of plasmapheresis. Subsequently, video assisted thoracoscopy with resection of the thymoma was done but the surgery was complicated with need for right pneumonectomy. On post-operative day 6, patient developed right sided tension pneumothorax requiring a 28 Fr chest tube placement resulting in continuous grade IV air leak. Chest CT scan revealed a right hydropneumothorax (Fig 1). Diagnostic bronchoscopy on day 10, showed absence of right main stem bronchus along with a 4mm bronchopleural fistula (Fig 2). Cultures from the bronchoscopy grew methicillin sensitive staphylococcus aureus and he was started on appropriate antibiotics. He continued to have PAL along with significant tidal volume loss which led to failed weaning on the ventilator. Unfortunately, he was deemed not a surgical candidate due to his ventilator dependence from pneumonia and poor nutritional status. On day 14, we repeated bronchoscopy and fibrin sealant was applied through a guide sheath, down the working channel which reduced the air leak but still persisted. Next day, bronchoscopy with deployment of size 5 spiration endobronchial valves was performed (Fig 3) which led to cessation of air leak and on day 20, patient was successfully weaned off ventilator support. Patient was treated for the empyema for 4 weeks and chest tubes were thereafter removed. He was then discharged to subacute rehabilitation after 57 days of hospitalization and 8 weeks later underwent surgical closure. DISCUSSION: BPF diagnosis and management requires a multidisciplinary approach. Patients with poor cardiopulmonary status, the risks of general anesthesia and surgical intervention pose a challenge. A variety of bronchoscopic options like EBVs, stents, ASD closure devices and occlusive material can be considered, primarily as temporizing measures. EBVs allow retrograde passage of air and infected secretions while blocking anterograde airflow. This reduces or stops the air leak and promotes healing. Their use in our patient allowed for weaning from high levels of oxygen support and liberation from mechanical ventilation. CONCLUSIONS: EBV placement is a minimally invasive procedure which can be performed to help with PAL associated with small BPF (<5mm) when surgery is not an option. REFERENCE #1: M. Lois, M. Noppen, Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management, Chest 128 (2005) 3955–3965. REFERENCE #2: Giddings O, Kuhn J, Akulian J. Endobronchial valve placement for the treatment of bronchopleural fistula: a review of the current literature. Curr Opin Pulm Med. 2014 Jul;20(4):347-51. doi: 10.1097/MCP.0000000000000063. PMID: 24811833. REFERENCE #3: Mahajan AK, Verhoef P, Patel SB, Carr G, Kyle Hogarth D. Intrabronchial valves: a case series describing a minimally invasive approach to bronchopleural fistulas in medical intensive care unit patients. J Bronchology Interv Pulmonol. 2012;19(2):137-141. doi:10.1097/LBR.0b013e318251c897 DISCLOSURES: No relevant relationships by Tejaswi Nadig, source=Web Response

Tension Pneumothorax With Persistent Air Leak in Critical COVID-19 Pneumonia With Acute Respiratory Distress Syndrome Treated With Intrabronchial Valves.

Tension Pneumothorax With Persistent Air Leak in Critical COVID-19 Pneumonia With Acute Respiratory Distress Syndrome Treated With Intrabronchial Valves.

Early Post-Transplant Persistent Pneumothorax, Dehiscence or No Dehiscence?

<h3>Introduction</h3> Early pleural complications following lung transplantation (LT) are common, ranging from 22-34%. Persistent air leaks early after transplant have been associated with increased post-operative mortality. They can result from airway complications such as anastomosis dehiscence or from a peripheral communication between the lung and the pleura. <h3>Case Report</h3> A 66-year-old female with end stage hypersensitivity pneumonitis and a prior episode of right pneumothorax was admitted to the hospital with worsening hypoxemic respiratory failure. She was found to have a new right pneumothorax which improved following chest tube insertion. She was listed for LT and remained hospitalized until a donor become available. Routine bronchoscopy preformed on POD 2, prior to extubation, showed no evidence of airway ischemia. On POD 6, worsening bilateral pneumothorax with severe subcutaneous emphysema were observed on chest X ray as well as a new air leak on the right sided chest tube. CT chest demonstrated grossly intact anastomosis; however, air was seen approximating the right anastomotic site raising concern for dehiscence. An additional chest tube was inserted with no improvement. Bronchoscopy demonstrated intact anastomoses with no airway ischemia reperfusion injury, however, an open RUL accessory bronchus was noted to take off from the native trachea (Figure 1A). A 6 mm <i>Spiration e</i>ndobronchial valve was deployed at the accessory RUL bronchus (Figure 1B) with resolution of the air-leak and pneumothorax, and subsequent chest tube removal. <h3>Summary</h3> Tracheal bronchus is a known bronchial anomaly, prevalence ranging from 0.1- 2%. Persistent air leak early after transplantation raises concern for airway complications. Albeit rare, the possibility of tracheal tree abnormalities, should be considered, especially in a stable well oxygenated patient. Intrabronchial valve placement can yield good results avoiding further invasive intervention in this highly immunosuppressed population.

CLOSURE OF A BRONCHOPLEURAL FISTULA WITH ONE-WAY ENDOBRONCHIAL VALVES WHILE ON HIGH-FREQUENCY OSCILLATORY VENTILATION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A bronchopleural fistula (BPF) is an abnormal sinus tract between the tracheobronchial tree and the pleural space whose presence is associated with increased morbidity, mortality and extended hospital duration. Additionally, a large airway defect can result in refractory hypercapnia rendering periprocedural ventilation exceedingly difficult. Preferred definitive management is surgical resection. However, for the non – surgical candidate a handful of bronchoscopic and pleural interventions, including compassionate placement of one – way valves, have been successfully described for the treatment of a persistent BPF. CASE PRESENTATION: A 25 – year old male with restrictive lung disease secondary to severe muscular dystrophy was admitted to a surgical ICU after a difficult intubation resulting in an emergent cricothyroidotomy and placement of two unilateral surgical chest tubes. The patient’s underlying lung disease combined with intra-parenchymal placement of one of the chest tubes resulted in mixed respiratory failure. Multiple modes of conventional ventilation with neuromuscular blockade were trialed with persistent life threatening hypercapnia prior to being stabilized on a High – Frequency Oscillatory Ventilator (HFOV). His clinical course was complicated by bacteremia, fungemia and a large continuous air-leak. On bronchoscopy, the right upper lobe (RUL) was identified as the anatomic origin of the defect following occlusion with a 5.5 Fr Fogarty Balloon catheter and resolution of the air leak. Definitive management was attempted by placement of four one – way Spriation endobronchial values within the RUL segments while concurrently on HFOV. Significant decrement of the air leak was successfully obtained as well as improvement of his oxygenation and ventilation. DISCUSSION: Chest trauma, including inadvertent intra – parenchymal placement of a chest tube is a rare cause of a bronchopleural fistula. We describe a case of a BPF complicated by a large persistent air leak with initial management via ventilation on a high frequency oscillatory ventilator followed by a novel attempted at definitive treatment with placement of endobronchial values while concurrently on HFOV. CONCLUSIONS: Compassionate placement of endobronchial one – way vales can be safely executed while on HFOV for management of a severe BPF in non – surgical candidates. Reference #1: Gilbert, C. R., Casal, R. F., Lee, H. J., Feller-Kopman, D., Frimpong, B., Dincer, H. E., … Yarmus, L. B. (2016). Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage. The Annals of Thoracic Surgery, 101(5), 1891–1896. doi: 10.1016/j.athoracsur.2015.10.113 Reference #2: Keshishyan, S., Revelo, A. E., & Epelbaum, O. (2017). Bronchoscopic management of prolonged air leak. Journal of Thoracic Disease, 9(S10). doi: 10.21037/jtd.2017.05.47 Reference #3: Ha, D. V., & Johnson, D. (2004). High frequency oscillatory ventilation in the management of a high output bronchopleural fistula: a case report. Canadian Journal of Anesthesia/Journal Canadien Danesthésie, 51(1), 78–83. doi: 10.1007/bf03018553 DISCLOSURES: No relevant relationships by Rohini Chatterjee, source=Web Response No relevant relationships by Michal Sobieszczyk, source=Web Response No relevant relationships by Bryce Warren, source=Web Response No relevant relationships by Whittney Warren, source=Web Response

Efficacy and Safety of the 9-mm Intrabronchial Valve in Patients with Advanced Emphysema

Background: Endoscopic valve therapy aims at lung volume reduction that is associated with improved lung function, exercise tolerance and quality of life in emphysema patients. The size of intrabronchial valves of the Spiration® Valve System (SVS) selected to achieve lobar occlusion may have an influence on treatment outcomes. Methods: 49 severe emphysema patients (M/F: 24/25, age: 64 ± 7 years), with complete interlobar fissures on the side intended to be treated, underwent treatment with at least one 9-mm intrabronchial valve implantation at 3 centers and were followed up at 30, 90 and 180 days after intervention. Changes in pulmonary function tests (PFT), 6-min walk test (6MWT), modified Medical Research Council (mMRC) dyspnea scale and chronic obstructive pulmonary disease assessment test scores as well as possible complications were recorded. Results: Forced expiratory volume in 1 s (FEV₁) improved significantly over the 6-month period of the study, and the proportion of patients achieving a minimal clinically important difference (MCID) for FEV₁ was 46.4% at 6 months. Regarding the remaining PFT values, the changes were not statistically significant at 6 months, but when looking at the MCIDs, 44.4% of the patients achieved the MCID decrease for residual volume. The 6MWT distance also improved statistically significantly, and an MCID increase of ≥26 m was reached by 41.7% of the patients. Furthermore, there was a statistically significant improvement in the mMRC score. The incidence of pneumothoraxes requiring drainage was 26.5% while a valve dislocation rate of 24% was observed but only in the lower lobes. Conclusions: Endoscopic lung volume reduction with the 9-mm SVS valves was associated with statistically significant but modest improvement of FEV₁, mMRC and 6MWT up to 6 months after intervention. These results were accompanied by an anticipated and acceptable risk profile. The relative increased incidence of device dislocation observed needs to be further elucidated.

Bronchoscopic lung volume reduction procedures for emphysema: A network meta-analysis.

Bronchoscopic lung volume reduction (BLVR) offers alternative novel treatments for patients with emphysema. Comprehensive evidence for comparing different BLVR remains unclear. To estimate the effects of different BLVR on patients with emphysema. PubMed, EMBASE, Cochrane Library, and Web of Science databases from January 2001 to August 2017 were searched. Randomized clinical trials evaluated effects of BLVR on patients with emphysema. The relevant information was extracted from the published reports with a predefined data extraction sheet, and the risk of bias was assessed with the Cochrane risk of bias tools. Pair-wise metaanalyses were made using the random-effects model. A random-effects network meta-analysis was applied within a Bayesian framework. The quality of evidence contributing to primary outcomes was assessed using the GRADE framework. 13 trials were deemed eligible, including 1993 participants. The quality of evidence was rated as moderate in most comparisons. Medical care (MC)was associated with the lowest adverse events compared with intrabronchial valve (IBV)(-2.5,[-4.70 to -0.29]), endobronchial valve (EBV) (-1.73, [-2.37 to -1.09]), lung volume reduction coils (LVRC) (-0.76, [-1.24 to -0.28]), emphysematous lung sealant (ELS) (-1.53, [-2.66 to -0.39]), and airway bypass(-1.57, [-3.74 to 0.61]). Adverse events in LVRC were lower compared with ELS (-0.77,[-2.00 to 0.47]). Bronchoscopic thermal vapor ablation (BTVA) showed significant improvement in FEV1 compared with MC (0.99, [0.37 to 1.62]), IBV (1.25, [0.25 to 2.25]), and LVRC (0.72, [0.03 to 1.40] ). Six minute walking distance (6 MWD) in ELS was significantly improved compared with other four BLVR, sham control, and MC (-1.96 to 1.99). Interestingly, MC showed less improvement in FEV1 and 6MWDcompared with EBV (-0.45, [-0.69 to -0.20] and -0.39, [-0.71 to -0.07], respectively). The mortality in MC and EBV was lower compared with LVRC alone (-0.38, [-1.16 to 0.41] and -0.50, [-1.68 to 0.68], respectively). BTVA and EBV led to significant changes in St George's respiratory questionnaire (SGRQ) compared with MC alone (-0.74, [-1.43 to -0.05] and 0.44, [0.11 to 0.78], respectively). BLVR offered a clear advantage for patients with emphysema. EBV had noticeable beneficial effects on the improvement of forced expiratory volume 1, 6MWD and SGRQ, and was associated with lower mortality compared with MC in different strategies of BLVR.

Bronchoscopic interventions for emphysema: Current status.

Chronic obstructive pulmonary disease is a prevalent and progressive disease. The recently developed bronchoscopic lung volume reduction (BLVR) techniques offer personalized therapeutic options in subgroups of patients with severe emphysema. Endobronchial and intrabronchial valves (EBV/IBV) achieve lung volume reduction by lobar atelectasis. The lung volume reduction coils (LVRCs) and bronchoscopic thermal vapor ablation (BTVA) induce tissue compression, either mechanically or through inflammatory processes. While the effects of EBV/IBV are reversible by removing the implants, the effects of LVRC are partially reversible and that of BTVA is irreversible. The presence of interlobar collateral ventilation (CV) impacts on EBV/IBV treatment outcome due to its mechanism of action. Therefore, using radiological and endoscopic techniques to assess CV has a vital importance. Current evidence of BLVR demonstrates acceptable safety and short-term clinical efficacy. However, head-to-head trials are lacking, and further research is needed to establish long-term clinical benefit, durability, and cost-effectiveness of these techniques.

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

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. 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. 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 2.5days (mean ± SD of 8.9 ± 12.4days). 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 4days (mean 6.0 ± 6.1days). This prospective registry adds to the growing body of literature supporting feasible and effective management of air leaks utilizing one-way valves.

Intrabronchial valves for persistent pulmonary air leaks in children

Abstract Background Surgery to address parenchymal lung disease in children is rare. One of the complications of the surgery is a persistent air leak (PAL). Intrabronchial valves (IBV), which received FDA approval for treating PAL in recent years, limit or exclude the inflow of air towards the pleura and allow air and secretions to flow towards central airways. The valves have been effective in adults with PAL but little has been published on their use in children. Methods Retrospective chart review was performed after IRB approval on patients treated with IBV after surgical excision of lung parenchyma. A literature review was then performed. Results 2 pediatric patients are presented. Patient 1, a 10 year old girl underwent excision of a lung mass that developed persistent air leak. Traditional conservative methods did not seal the air leak for 23 days but an IBV sealed the leak in 24 h. Patient 2, a 6 year old boy underwent a pneumonectomy with post-operative bronhical leak. The bronchus was repaired but a leak persisted for 36 days. An IBV sealed the leak immediately. Conclusion Intrabronchial valves can be used for the management of persistent pulmonary air leaks. We propose a tentative algorithm for using the devices in children with PAL.

Bronchoscopic Lung Volume Reduction in Patients with Severe Emphysema.

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive procedure for patients with symptomatic severe emphysema who may not be candidates for surgical lung volume reduction. BLVR has been shown to improve both functional and clinical outcomes with a relatively low risk of severe complications. Any potential candidate to BLVR should be on optimal pharmacological and nonpharmacological treatment. Radiographic and pulmonary function testing provide key data to help identify potential BLVR candidates. A variety of BLVR techniques have been published with different associated benefits and risks. Current strategies include either blocking procedures such as endobronchial valves and intrabronchial valves or nonblocking procedures such as endobronchial coils and bronchoscopic thermal vapor ablation. The aim of this review is to describe current options of BLVR including their efficacy and safety based on available data.

Evidence of Efficacy of Intrabronchial Valves for Persistent Air leak

Evidence of Efficacy of Intrabronchial Valves for Persistent Air leak

Assessment of Fissure Integrity in Patients With Intrabronchial Valves for Treatment of Prolonged Air Leak

Intrabronchial valves (IBVs) are a treatment alternative for persistent air leak (PAL). However, there is a paucity of evidence regarding whether the absence of collateral ventilation (CV) can predict successful treatment of PAL with IBV placement. We assessed whether absence of CV measured by fissure integrity could predict successful resolution of PAL with IBV placement. A multicenter, retrospective study was performed. Patients who underwent IBV placement for PAL were identified. Chest computed tomography analysis via VIDA Diagnostics was used to assess CV. CV was present if the treated lobe was adjacent to a fissure that was <90% complete. A total of 81 valves were placed in 26 patients (median, 3 per patient). A total of 16 patients without CV underwent IBV placement: 14 patients had complete resolution of PAL with a median time from IBV placement to air leak resolution of 4.5 days and 2 patients required subsequent procedures to manage the PAL. In a subset of patients without CV who underwent complete lobar occlusion with IBV (n= 8), median time to PAL resolution was 3 days, whereas in patients without CV who underwent incomplete lobar occlusion with IBV (n= 6), median time PAL resolution was 6.5 days (p= 0.045). All 10 patients with CV underwent IBV placement and complete lobar occlusion: 4 patients had complete PAL resolution with a median time from IBV placement to PAL resolution of 17.5 days and 6 patients required subsequent procedures to manage their PAL. PAL treatment with IBV is more successful in patients without CV, especially when complete lobar occlusion with IBV is achieved.

History of lung volume reduction procedures.

Lung volume reduction (LVR) procedures for emphysematous patients were firstly introduced in the second half of the twentieth century. Over time, from the first invasive surgical procedures, new less invasive techniques have been conceived. In regards to the surgical approach, the adoption of VATS and the execution, in selected centers, of a non-resectional approach, with folding of less functional lung tissue, reduced mortality and adverse events risks. As regards to the bronchoscopic approach, endobronchial valves (EBV) and intrabronchial valves (IBV) were initially proposed in the early 2000s to obtain segmental or lobar atelectasis of the more compromised lung parenchyma. Despite showing promising results with respect to improvement of pulmonary function tests, particularly forced expiratory volume in 1st second (FEV1), and quality of life, and a good safety profile, valves showed disappointing results in presence of collateral ventilation, such as in cases of incomplete fissures. To overcome this technical issue, in the last 10 years, endobronchial coils have been designed and used. Having a compressive effect on the lung parenchyma where they are located, they are not affected by collateral ventilation. Randomized control trials (RCTs) on endobronchial coils showed a significant improvement in FEV1 and quality of life, however this technique was not immune to side effects, particularly low respiratory tract infections and pneumothoraces. Besides bronchial valves (BV) and coils, airway by-pass stents have also been evaluated in a RCT but without reaching the desired endpoints. Other innovative procedures recently considered and delivered through bronchoscopy regards thermal energy, with vapour therapy, to achieve a scarring reaction of the emphysematous lung parenchyma, and polymeric foams used as lung sealants to achieve absorptive atelectasis. In conclusion, LVR procedures may be considered in carefully selected patients with symptomatic emphysema and severe lung hyperinflation, and might be personalized according to the anatomical characteristics of emphysematous area.

Effectiveness and safety of unilateral endobronchial valve applying to severe emphysema: a meta-analysis

Background: Bronchoscopic lung volume reduction (BLVR) is now deemed to be better for severe emphysema patients when comparing to surgical lung volume reduction surgery (LVRS). This article aims to evaluate the effectiveness and the safety of BLVR using unilateral one-way endobronchial valve (EBV) by a meta-analysis. Methods: We performed a systematic search of available databases, including PubMed, EMBASE, the Cochrane Library, and four domestic databases up to January 28th 2018. Two reviewers viewed all references according to selection criteria independently. The handbook of Cochrane quality assessment system was used to assess the quality of each literature. Randomized controlled trials (RCTs) data were combined and performed for a meta-analysis by using RevMan 5.3 software. Results: This meta-analysis included nine studies. Forced expiratory volume in 1 second (FEV1) in the intervention group improved when comparing with the EBV used control group [standardized mean difference (SMD) =0.57, 95% confidence interval (CI): 0.29–0.86]. Six-minute walking distance (6MWD) [mean difference (MD) =62.35, 95% CI: 32.48–92.22] also improved. And the St. George’s Respiratory Questionnaire (SGRQ) score in the intervention group decreased (MD =−5.54, 95% CI: −7.41 to −3.67). Six months follow-up RCTs reported incidence rates of pneumothorax, hemoptysis, chronic obstructive pulmonary disease (COPD) exacerbation with hospitalization were higher in the BLVR (EBV) group, relative risk (RR) =10.11 (95% CI: 3.46–29.54), RR =5.71 (95% CI: 1.35–24.20), RR =1.96 (95% CI: 1.15–3.32), respectively. And incidence rates of death, massive hemoptysis, pneumonia, COPD exacerbation without hospitalization and respiratory failure between two groups had no significant difference. Conclusions: BLVR using one-way EBV but not intrabronchial valve (IBV) may be an effective and safe procedure for treating COPD patients with severe emphysema.

Bronchoscopic Lung Volume Reduction Procedures for Emphysema: A Network Meta-Analysis

Importance: Bronchoscopic lung volume reduction (BLVR) offers alternative novel treatments for patients with emphysema. Comprehensive evidence for comparing different BLVR remains unclear. Objective: To estimate the effects of different BLVR on patients with emphysema. DataSources: PubMed, EMBASE, Cochrane Library, and Web of Science databases from January 2001 to August 2017were searched. Study Selection: Randomized clinical trials (RCT) evaluated effects of BLVR on patients with emphysema. Data Extraction and Synthesis: The relevant information was extracted from the published reports with a predefined data extraction sheet, and the risk of bias was assessed with the Cochrane risk of bias tools. Main Outcomes and Measures: Pair-wise meta-analyses were made using the random-effects model. A random-effects network meta-analysis was applied within a Bayesian framework. The quality of evidence contributing to each network estimate was assessed using the GRADE framework. Results: 13 trials were deemed eligible, including 1993 participants. The quality of evidence was rated as moderate in most comparisons. Medical care (MC)was associated with the lowest adverse events compared with intra-bronchial valve (IBV)(-2.5,[-4.70 to -0.29]), endobronchial valve (EBV) (-1.73, [-2.37 to -1.09]), lung volume reduction coils (LVRC) (-0.76, [-1.24 to -0.28]), emphysematous lung sealant (ELS) (-1.53, [-2.66 to -0.39]), and airway bypass(-1.57, [-3.74 to 0.61]).Adverse events in LVRC were lower compared with ELS (-0.77,[-2.00 to 0.47]).Bronchoscopic thermal vapor ablation (BTVA) showed significant improvement inFEV1 compared with MC (0.99, [0.37 to 1.62]), IBV (1.25, [0.25 to 2.25]), and LVRC (0.72,[0.03 to 1.40]).6 MWT in ELS was significantly improved compared with other four BLVR, sham control, and MC (-1.96 to 1.99).Interestingly, MC showed less improvement in FEV1 and 6 MWT compared with EBV (-0.45, [-0.69 to -0.20] and -0.39, [-0.71 to -0.07], respectively).The mortality in MC and EBV was lower compared with LVRC alone (-0.38, [-1.16 to 0*41] and -0.50, [-1.68 to 0*68], respectively). BTVA and EBV led to significant changes in SGRQ compared with MC alone (-0.74, [-1.43 to -0.05] and 0.44, [0.11 to 0.78], respectively). Conclusions and Relevance: BLVR offered a clear advantage for patients with emphysema. EBV had noticeable beneficial effects on the improvement of FEV1, 6MWTand SGRQ, and was associated with lower mortality compared with MC in different strategies of BLVR. Funding: This project was supported by National major research program on Natural Science of China (91542164). Competing interests: The authors declare that they have no competing financial interests. Ethics Approval Statement: ??

Application of Intrabronchial Valves in High Risk Patients with Bronchopleural Fistula: an Alternative Therapeutic Option

Persistent air leak or bronchopleural fistula (BPF) is a challenging and frequently observed problem after pulmonary resection and may lead to prolonged chest tube therapy. One efficient nonsurgical approach to manage such a fistula is the application of intrabronchial valves. This may support earlier chest tube removal and hospital discharge. Between 04/2015 and 03/2017, n = 8 patients (n = 4 female) with severe pleural empyema and necrotising lung tissue defects developed prolonged air leak and persistent BPF after surgery. Radiological and bronchoscopical investigations revealed the presence of a BPF. For closure, intrabronchial valves were endoscopically inserted into the affected bronchi. In patients with repeat development of empyema, a chest wall window was required (n = 6 patients). The mean age was 61 years (45 - 85 years). After repeated surgical debridement, the space was sterile and the chest wall window was closed. After valve placement, air leaks were no longer detectable. In all patients, the procedures were well tolerated without any negative events. After successful valve placement, chest tubes could be removed in all n = 8 patients within 7 days (3 - 15 days) and patients were discharged thereafter. Placement of intrabronchial valves presents an alternative option to conventional surgical and non-surgical methods for the treatment of postoperative persistent air leak or BPF. Particularly in high risk patients, this procedure is safe and effective.