One-way Endobronchial Valves Research Articles

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.

Valve therapy in patients with emphysematous type of chronic obstructive pulmonary disease (COPD): from randomized trials to patient selection in clinical practice.

In recent years a number of endoscopic methods have emerged to treat patients with severe emphysematous type of chronic obstructive pulmonary disease (COPD), who are primarily symptomatic due to hyperinflation despite optimal medical management. Of these techniques, implantation of endobronchial one-way valves into targeted airways of isolated emphysematous lobes appears to be one of the most promising innovations. Results from randomized controlled trials of valve therapy for emphysema show consistent benefits in terms of lung function, exercise capacity, symptoms, and quality of life. This review aims to provide a comprehensive summary of the currently available scientific data, discussion of typical treatment related side effects, and recommendations for patient selection in clinical practice.

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.

Endobronchial valve for treatment of persistent air leak complicating spontaneous pneumothorax.

Endobronchial one-way valves have been proposed as treatment for persistent air leak complicating spontaneous pneumothorax in which surgical intervention is not feasible. However, published data on efficacy, safety, and factors associated with success are scanty. This is a retrospective study of 37 patients at a general hospital from 2008 to 2016. The impact of endobronchial valve implantation on the time to air-leak cessation after bronchoscopy was evaluated. The median patient age was 71 years. The majority of patients were males (92%), were ever-smokers (83%), had at least one co-morbidity (97%), and had secondary spontaneous pneumothorax (89%). Nineteen patients (51%) had a mean of 2.6 endobronchial valves implanted (range, 1-6). The air leak ceased within 72 hours for only eight patients (22% of the complete cohort), with immediate air-leak cessation after completion of endobronchial valve implantation. All six successful cases that had computed tomographic data of the thorax were shown to have bilateral intact interlobar fissures. The median (interquartile range) Charlson co-morbidity index was 1 (0.25-1) and 2 (1-3) for the success group and failure group, respectively (P=0.029). All patients in the no-endobronchial valve group survived, whereas three patients in the endobronchial valve group died within 30 days of endobronchial valve implantation. Only a small proportion of cases of endobronchial valve implantation for air leak complicating pneumothorax had unequivocal success. Intact bilateral interlobar fissures appear to be a necessary, though not sufficient, condition for success. Patients with fewer medical co-morbidities and immediate air-leak cessation after endobronchial valve implantation have a higher likelihood of success.

Bronchoscopic lung volume reduction with endobronchial valves for heterogeneous emphysema: long-term results.

Bronchoscopic lung volume reduction (BLVR) with implant of one-way endobronchial valves (EBV) is a feasible treatment for management of heterogeneous emphysema (HE) with clinical benefits in the early follow-up. We aimed to evaluate the long-terms results and safety of this procedure in a consecutive series of patients with HE. It was a retrospective single center study including all consecutive patients with HE undergoing EBV treatment and completing at least 5 years of long-term follow-up. Patients were splitted into Collapse and No-Collapse Group if a lobar collapse or not were obtained after valves implant. The difference of functional data and quality of life (QoL) before and after the procedure (measured at 3, 6, 9, 12 months from the valve implantation, and then annually up to a maximum of 5 years) were statistically evaluated to show the long-term benefits of the procedure (primary endpoint). Yet, morbidity, mortality and survival rates were also recorded to show the safe of the treatment (secondary endpoint). Thirty-three patients were included in the study. Of these, three patients underwent a bilateral treatment. Collapse Group patients (n=27) presented a significant improvement in FEV1% (+17%; P=0.001); in FVC% (+18%; P=0.002); in RV% (-39%; P=0.003); in 6MWT (P=0.001) and in SGRQ (P=0.001) in the early 12 months of follow-up and no significant decline was seen later. Conversely, No-Collapse Group (n=9) did not have significant benefits. No major complications and death related to the procedure were observed. The 1-,2-,3-,4- and 5-year survival rates were 100%, 90%, 78%, 71% and 71%, respectively. Collapse Group had a better survival than No-Collapse Group (45 vs. 24 months; P=0.001). Our study confirmed that the lobar collapse is the key success of EBV treatment and the early improvements of respiratory function could be maintained up to five years from the valves implant.

Pop-Up MEMS One-Way Endobronchial Valve for Treatment of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of morbidity in aging populations worldwide. One of the most debilitating effects of COPD is hyperinflation, which restricts the function of healthier portions of the lung, diaphragm, and heart. Bronchoscopic lung volume reduction (BLVR) is a minimally invasive technique to reduce hyperinflation, consisting of one-way valves inserted bronchoscopically that slowly drain the diseased lobe of its accumulated air. Presented here is a novel redesign of current BLVR devices using pop-up microelectromechanical systems (MEMS) manufacturing to create microscale check valves. These operate more reliably than current polymer valves and allow tunable airflow to accommodate widely varying patient physiologies. Analysis and ex vivo testing of the redesigned valve predicted the valve should outlast current valves with a lifetime of well over 8 yr and showed airflow controllability within desired physiological ranges of up to 1.2 SLM. The valve resists backflow twice as well as the current standard valves while permitting comparable forward flow.

Pleural Adhesion Assessment as a Predictor for Pneumothorax after Endobronchial Valve Treatment

Background: Pneumothorax after bronchoscopic lung volume reduction using one-way endobronchial valves (EBVs) in patients with advanced emphysema occurs in approximately 20% of patients. It is not well known which factors predict the development of pneumothorax. Objective: To assess whether pleural adhesions on pretreatment high-resolution computed tomography (HRCT) scans are associated with pneumothorax occurrence after EBV treatment. Methods: HRCT scan analyses were performed on all patients who received EBV treatment in a randomized controlled trial. Three blinded readers scored adhesions by number and by measuring the longest axis of each pleural adhesion in the treated lung. The Pleural Adhesion Score (PAS) was calculated by adding 1 point for each small pleural lesion (<1 mm), 5 points for each medium-sized lesion (1-5 mm), and 10 points for each large lesion (>5 mm). Results: The HRCT scans of 64 treated patients were assessed, of whom 14 developed pneumothorax. Patients who developed pneumothorax had a higher median number of pleural adhesions, 2.7 (IQR 1.9-4) compared to 1.7 (1-2.7) adhesions in the group without pneumothorax (p < 0.01). The PAS in the group with pneumothorax was higher compared to that in the group without: 14.3 (12.4-24.1) versus 6.7 (3.7-11.2) (p < 0.01). A threshold PAS of ≥12 was associated with a higher risk of pneumothorax (OR 13.0, 95% CI 3.1-54.9). A score <12 did not rule out the occurrence of pneumothorax. Conclusion: A higher number of pleural adhesions on HRCT with a subsequent higher PAS in the treated lung is associated with a higher occurrence of pneumothorax after EBV treatment.

Current treatment of tracheoesophageal fistula.

Tracheoesophageal fistulas (TEFs) often occur with esophageal or bronchial carcinoma. Currently, we rely on implantation of delicate devices, such as self-expanding and silicone stents, in the esophagus or trachea to cover the fistula and expand the stenosis in order to relieve patient pain. However, because each case is different, our approach may not be effective for every patient. Consequently, new devices and technology have emerged to address these situations, such as degradable stents, Amplatzer® devices, endobronchial one-way umbrella-shaped valves, and transplantation of mesenchymal stem cells. Although some studies have shown such alternatives can be reasonable solutions in special cases, further development of other new and effectual techniques is of utmost importance.

Endobronchial Valves for Endoscopic Lung Volume Reduction: Best Practice Recommendations from Expert Panel on Endoscopic Lung Volume Reduction

Endoscopic lung volume reduction (ELVR) is being adopted as a treatment option for carefully selected patients suffering from severe emphysema. ELVR with the one-way endobronchial Zephyr valves (EBV) has been demonstrated to improve pulmonary function, exercise capacity, and quality of life in patients with both heterogeneous and homogenous emphysema without collateral ventilation. In this “expert best practices” review, we will highlight the practical aspects of this therapy. Key selection criteria for ELVR are hyperinflation with a residual volume >175% of predicted, forced expiratory volume <50% of predicted, and a 6-min walking distance >100 m. Patients with repeated infectious complications, severe bronchiectasis, and those with unstable cardiovascular comorbidities should be excluded from EBV treatment. The procedure may be performed with either conscious sedation or general anesthesia and positive pressure mechanical ventilation using a flexible endotracheal tube or a rigid bronchoscope. Chartis and EBV placement should be performed in 1 procedure when possible. The sequence of valve placement should be orchestrated to avoid obstruction and delivery of subsequent valves. If atelectasis has not occurred by 1 month after procedure, evaluate valve position on CT and consider replacing the valves that are not optimally positioned. Pneumothorax is a common complication and typically occurs in the first 2 days following treatment. A management algorithm for pneumothorax has been previously published. Long-term sequelae from EBV therapy do occur but are easily manageable.

One-Year Follow-Up after Endobronchial Valve Treatment in Patients with Emphysema without Collateral Ventilation Treated in the STELVIO Trial

Background: One-way endobronchial valve (EBV) treatment has shown safety and efficacy at 6 months after treatment in patients with severe emphysema and confirmed absence of interlobar collateral ventilation. Longer follow-up in this subgroup is not available. Objectives: To investigate the efficacy and safety of EBV treatment of the STELVIO cohort at a 1-year follow-up. Methods: Emphysema patients who have been treated with EBV in the STELVIO trial were invited for a voluntary 1-year follow-up visit. Both the original treatment group and the control group who crossed over to treatment have been included. Analyses are performed on the patients who attended the 1-year follow-up visit. Results: Sixty-four patients received EBV treatment. At 1 year, 40 patients (26 female; mean age 59 ± 8 years; FEV₁ 0.86 ± 0.29 L; RV 4.56 ± 1.00 L; 6MWD 367 ± 78 m; and SGRQ 56 ± 13 points) visited the hospital. Significant improvements (p < 0.001) were found for FEV₁ (+17%, 95% CI, 11 to 24), RV (-687 mL, 95% CI, -918 to -456), 6MWD (+61 m, 95% CI, 42 to 80), and SGRQ (-11 points, 95% CI, −17 to −6). Two patients died: 1 after 58 days due to progressive respiratory failure and 1 after 338 days of follow-up due to a myocardial infarction. Seventeen percent of the patients underwent valve replacement and 22% of the initially treated patients had permanent valve removal. In 22% of the patients, pneumothoraces occurred before 6 months, and none occurred between 6 and 12 months. Conclusions: EBV treatment results in clinically relevant benefits at 1 year of follow-up. Maintenance bronchoscopies to achieve this are needed. This study supports the use of EBV treatment in carefully selected patients with severe emphysema without collateral ventilation.

Predicting Lung Volume Reduction after Endobronchial Valve Therapy Is Maximized Using a Combination of Diagnostic Tools

Background: Bronchoscopic lung volume reduction using one-way endobronchial valves (EBVs) has been proven to be effective in patients with severe emphysema. However, the selection of patients without collateral ventilation prior to treatment is critical for procedural success. Collateral ventilation can be assessed directly with the Chartis system or indirectly using computed tomography (CT) fissure analysis. Objectives: We retrospectively evaluated the diagnostic value of a combination of the quantitative CT interlobar fissure completeness score (FCS) and Chartis in predicting responders to EBV therapy. Methods: CT data from four prospective studies were pooled and analyzed using semiautomated software to quantify the completeness of interlobar fissures. These FCSs were compared to a reference standard of achieving ≥350 ml of target lobe volume reduction after EBV treatment. Using a receiver operating characteristic curve, optimal thresholds predictive of complete fissures (responders) and incomplete fissures (non-responders) were determined. A subgroup of patients with partially complete fissures was identified, where software had lower accuracy. The complementary value of Chartis was investigated in this group. Results: A fissure was defined as complete (FCS >95%), incomplete (FCS <80%), or partially complete (80% < FCS < 95%). The positive predictive value (PPV) of complete fissures is 88.1%, and the negative predictive value (NPV) is 92.9%, with an overall accuracy of 89.2%. Chartis was utilized in patients with partially complete fissures, with a PPV of 82.3%, an NPV of 84.6%, and an accuracy of 83.3%. Conclusion: Combining diagnostic tools could reduce the burden on patients and the healthcare system while providing clinicians with a better means for patient selection for EBV therapy.

Invited Commentary

Invited Commentary

Fissure Integrity and Volume Reduction in Emphysema: A Retrospective Study

Background: One-way endobronchial valves (EBVs) relieve symptoms of emphysema, particularly in patients without collateral ventilation between the target and adjacent lobes. Pretreatment knowledge of fissure integrity could serve as an aid in indicating EBV interventions. Objective: This study aimed to investigate the relationship between software-measured lung fissure integrity and clinically relevant lung volume reduction (≥350 ml) in emphysema patients treated with one-way EBVs using a lobar exclusion strategy. Methods: Of 108 patients treated between March 2008 and July 2014, 38 had both baseline and follow-up computed tomography (CT) scans acquired following a specific protocol for quantitative CT analysis and were included in the study (total of 39 treatments, two lungs treated in 1 patient). Outcome measures were fissure integrity measured on baseline CT scans, difference between pre- and postoperative lung volume (considering the lowest measured postoperative volume), and correlation between fissure integrity and volume change. Results: Fissure integrity ≥75% correlated with volume reduction ≥350 ml (Spearman coefficient: -0.65; p < 0.01). The mean and median volume reductions were 1,223.96 ± 907.5 ml and 663 ml, respectively, for lungs with fissure integrity ≥75% (n = 31). The accuracy of fissure integrity ≥75% in predicting a volume reduction was 87.2%. The positive predictive value of fissure integrity ≥75% to predict a volume reduction ≥350 ml was 83.9%, and it was 70% for fissure integrity 75-90% and 90.5% for fissure integrity >90%. Conclusions: A target lobe volume reduction using EBVs is possible with lung fissure integrity ≥75%. For patients with fissure integrity between 75 and 90%, a further evaluation of interlobar ventilation should be performed. A clinically relevant volume reduction following treatment with EBVs is likely with any level of fissure integrity >90%.

31 - A Placebo-Controlled, Randomized Trial of Mesenchymal Stromal Cells Combined with One-Way Endobronchial Valve Therapy in Severe COPD

Rationale: Chronic obstructive pulmonary disease (COPD) is a devastating disease affecting millions worldwide, and therapeutic options are limited. One-way endobronchial valves (EBV) have been used in emphysema patients with dynamic hyperinflation, heterogeneity, and collateral ventilation to reduce lobar volume and improve lung function. However, EBV may increase rates of respiratory infection, COPD exacerbation, and hemoptysis. Mesenchymal stromal cells (MSCs) secrete antibacterial peptides, promote the anti-inflammatory M2 phenotype, and increase phagocytic activity. Thus, we hypothesized that administration of MSCs prior to EBV placement would improve lung function and quality of life in patients with severe heterogeneous COPD.

Sequential Bilateral Bronchoscopic Lung Volume Reduction With One-Way Valves for Heterogeneous Emphysema

Clinical benefits of bronchoscopic lung volume reduction with one-way endobronchial valves have been reported for heterogeneous emphysema after unilateral treatment. We assessed the potential role of contralateral treatment to prolong the benefits obtained with the first procedure. This was a retrospective multicenter study including consecutive patients with heterogeneous emphysema undergoing bronchoscopic valves deployment during the last 4 years. Patients were split into two groups depending on the procedure (unilateral versus bilateral). The intergroup differences were evaluated to assess the viability, effectiveness, and safety of the bilateral procedure. Forty-nine patients were enrolled. Of these, 14 (28%) had a sequential bilateral procedure mainly due to loss of the clinical benefits obtained with the first treatment. A significant improvement of forced expiratory volume in 1 second (p < 0.05), forced vital capacity (p<0.05), residual volume (p < 0.05), 6-minute walking test (p< 0.05), and St. George respiratory questionnaire (p< 0.02) was achieved after the second procedure. These results were maintained during follow-up. There was nosignificant difference regarding the changes of forced expiratory volume in 1 second (p= 0.4), forced vital capacity (p= 0.08), residual volume (p= 0.9), 6-minute walking test (p= 0.3), and St. George respiratory questionnaire (p= 0.1) between the bilateral and unilateral groups. A sequential bilateral approach seems to be a valid strategy to improve respiratory function in patients with bilateral heterogeneous emphysema who have lost the benefits obtained with the first procedure.

Another STEP forward in emphysema treatment

Patients with severe chronic obstructive pulmonary disease (COPD) suffer on a daily basis, despite important efforts to support this large patient population with pharmacotherapy. To potentially relieve symptoms, innovative bronchoscopic treatments have been developed in the past decade: the one-way endobronchial valve therapy for patients with severe emphysema and absence of interlobar collateral ventilation;1 the trans-bronchial airway bypass for severe emphysema, relying on the presence of collateral ventilation;2 nitinol coil treatment for a wide range of emphysema phenotypes independent of collateral ventilation;3 parasympathetic lung denervation for patients with COPD who respond well to anticholinergic agents;4 and sclerosing therapies such as crosslink compounds5 and steam,6 both of which target the most diseased parenchymal defects.

Successful treatment of persistent postoperative air leaks following the placement of an endobronchial one-way valve

Treatment of persistent air leaks due to pulmonary resection in pathological conditions of the lung involve a very large spectrum of available methods, from chest drainage and placement of Heimlich valves to surgical repair or pleural decortication. However, in some of these patients surgery may be contraindicated. This report describes an endobronchial approach to the control of marked and prolonged air leaks in four patients using a newly designed one-way airway valve (Pulmonx Corporation; Redwood City, Ca.USA) placed into the segmental bronchus that is the source of air leakage. As the device is a one-way inspiratory airway blocker, it can be used to control persistent air leaks while maintaining the drainage of mucus. This approach potentially provides an effective nonsurgical and minimally invasive alternative addition to the armamentarium of treatments for patients who suffer with persistent post-operative air leaks where other methods have failed or in frail patients who are categorised as a high surgical risk.

Endobronchial Valves for Emphysema without Interlobar Collateral Ventilation

BackgroundBronchoscopic lung-volume reduction with the use of one-way endobronchial valves is a potential treatment for patients with severe emphysema. To date, the benefits have been modest but have been hypothesized to be much larger in patients without interlobar collateral ventilation than in those with collateral ventilation.MethodsWe randomly assigned patients with severe emphysema and a confirmed absence of collateral ventilation to bronchoscopic endobronchial-valve treatment (EBV group) or to continued standard medical care (control group). Primary outcomes were changes from baseline to 6 months in forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and 6-minute walk distance.ResultsEighty-four patients were recruited, of whom 16 were excluded because they had collateral ventilation (13 patients) or because lobar segments were inaccessible to the endobronchial valves (3 patients). The remaining 68 patients (mean [±SD] age, 59±9 years; 46 were women) were randomly assigned to the EBV group (34 patients) or the control group (34). At baseline, the FEV1 and FVC were 29±7% and 77±18% of the predicted values, respectively, and the 6-minute walk distance was 374±86 m. Intention-to-treat analyses showed significantly greater improvements in the EBV group than in the control group from baseline to 6 months: the increase in FEV1 was greater in the EBV group than in the control group by 140 ml (95% confidence interval [CI], 55 to 225), the increase in FVC was greater by 347 ml (95% CI, 107 to 588), and the increase in the 6-minute walk distance was greater by 74 m (95% CI, 47 to 100) (P<0.01 for all comparisons). By 6 months, 23 serious adverse events had been reported in the EBV group, as compared with 5 in the control group (P<0.001). One patient in the EBV group died. Serious treatment-related adverse events in this group included pneumothorax (18% of patients) and events requiring valve replacement (12%) or removal (15%).ConclusionsEndobronchial-valve treatment significantly improved pulmonary function and exercise capacity in patients with severe emphysema characterized by an absence of interlobar collateral ventilation. (Funded by the Netherlands Organization for Health Research and Development and the University Medical Center Groningen; Netherlands Trial Register number, NTR2876.)

Endoscopic Lung Volume Reduction with Endobronchial Valves in Patients with Severe Emphysema and Established Pulmonary Hypertension

Background: One of the most common forms of pulmonary hypertension (PH) is that associated with chronic obstructive pulmonary disease (COPD). So far, patients with severe emphysema and established PH have been excluded from endoscopic lung volume reduction (ELVR) therapy due to the risk of right heart decompensation. Objective: The aim of this pilot study was to evaluate the feasibility and efficacy of ELVR using one-way endobronchial valves (EBV) in this specific group of patients. Methods: We prospectively included 6 patients with COPD, severe heterogeneous emphysema, and established PH who underwent right heart catheterization and clinical assessments before and 90 days after ELVR with unilateral EBV placement. Results: This study was not powered to measure any statistical differences in endpoints. Ninety days after ELVR, the symptoms, lung function, and hemodynamics improved in 5 out of 6 patients (1 patient normalized and 1 slightly worsened). The mean hemodynamics improved from baseline to 90 days after ELVR as follows: mean pulmonary artery pressure, -2.5 ± 3.5 mm Hg; pulmonary arterial wedge pressure, -4.3 ± 8.3 mm Hg; cardiac index, +0.3 ± 0.6 l/min/m², and 6-min walk distance, +59 ± 99 m. ELVR was performed without PH-related complications in all patients. Conclusion: To our knowledge, this is the first prospective, single-center pilot study to evaluate the feasibility and efficacy of ELVR in patients with established PH. ELVR was feasible and resulted in an improvement of clinical and hemodynamic parameters in 5 out of 6 patients. These results have to be further confirmed in larger-scale controlled studies.

Endobronchial occlusion with one-way endobronchial valves: A novel technique for persistent air leaks in children

PurposeIn children, persistent air leaks can result from pulmonary infection or barotrauma. Management strategies include surgery, prolonged pleural drainage, ventilator manipulation, and extracorporeal membrane oxygenation (ECMO). We report the use of endobronchial valve placement as an effective minimally invasive intervention for persistent air leaks in children. MethodsChildren with refractory prolonged air leaks were evaluated by a multidisciplinary team (pediatric surgery, interventional pulmonology, pediatric intensive care, and thoracic surgery) for endobronchial valve placement. Flexible bronchoscopy was performed, and air leak location was isolated with balloon occlusion. Retrievable one-way endobronchial valves were placed. ResultsFour children (16 months to 16 years) had prolonged air leaks following necrotizing pneumonia (2), lobectomy (1), and pneumatocele (1). Patients had 1–4 valves placed. Average time to air leak resolution was 12 days (range 0–39). Average duration to chest tube removal was 25 days (range 7–39). All four children had complete resolution of air leaks. All were discharged from the hospital. None required additional surgical interventions. ConclusionEndobronchial valve placement for prolonged air leaks owing to a variety of etiologies was effective in these children for treating air leaks, and their use may result in resolution of fistulae and avoidance of the morbidity of pulmonary surgery.