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Treatment of persistent air leak with endobronchial valves: a case report
EDİTÖRE MEKTUP
LETTER TO THE EDITOR
doi • 10.5578/tt.8062
Tuberk Toraks 2015;63(2):142-144
Geliş Tarihi/Received: 21.07.2014 • Kabul Ediliş Tarihi/Accepted: 08.08.2014
Treatment of persistent air
leak with endobronchial
valves: a case report
Erdoğan ÇETİNKAYA1
Zehra YAŞAR2
Murat ACAT3
1
Clinic of Chest Diseases, Yedikule Chest Diseases and Chest Surgery Training and
Research Hospital, Istanbul, Turkey
1
Yedikule Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi,
Göğüs Hastalıkları Kliniği, İstanbul, Türkiye
2
Department of Chest Diseases, Faculty of Medicine, Abant Izzet Baysal
University, Bolu, Turkey
2
Abant İzzet Baysal Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı,
Bolu, Türkiye
3
Department of Chest Diseases, Faculty of Medicine, Karabuk University,
Karabuk, Turkey
3
Karabük Üniversitesi Tıp Fakültesi, Göğüs Hastalıkları Anabilim Dalı, Karabük,
Türkiye
INTRODUCTION
Persistent air leaks are frequent after pulmonary
resection, but can occur as a complication of lung
diseases especially chronic obstructive lung disease
(COPD) (1). It may affect up to 20% of COPD patients
(2). Current treatment options of prolonged air leaks
involve prolonged tube thoracostomy drainage,
pleurodesis, surgical decortication or surgical repair. In
patients who are not candidates for surgical treatment,
alternative methods can be used such as endobronchial
approaches and radiotherapy (3,4). In this case, an
endobronchial valve was inserted by flexible
bronchoscopy for persistent air leakage, resulting in a
complete resolution and lung reexpansion in patient
with COPD.
CASE REPORT
63-year-old male patient applied to emergency clinic
with acute-onset dyspnea and substernal chest pain.
He had a history of 60 pack-year smoking and ten
years before that, he had been first told that he had
emphysema and was treated with inhaled
bronchodilators. Because of worsening dyspnea, he
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was treated with bullectomy five years ago. He had
been admitted to the hospital for three times with a
similar presentation; a spontaneous, right basal
pneumothorax and was treated with tube
thoracostomy. He was conscious, with vital signs of
arterial blood pressure 135/80 mmHg, the heart rate
92 beats per minute, respiratory rate 28 per minute
and an oxygen saturation of 89% at room air. There
were decreased respiratory sounds in all zones on the
right lung auscultation. Chest imaging demonstrated
a total pneumothorax in the right lung (Figure 1). On
thoracic-computed tomography (CT), bullous areas at
the apexes of both lungs and a right pneumothorax
were observed (Figure 2). Tube thoracostomy was
performed. Although he had clinically improved,
there was no improvement of the right pneumothorax,
therefore surgery was considered. But this was
Yazışma Adresi (Address for Correspondence)
Dr. Zehra YAŞAR
Abant İzzet Baysal Üniversitesi Tıp Fakültesi,
Göğüs Hastalıkları Anabilim Dalı, Gölköy, BOLU - TURKEY
e-mail: [email protected]
Çetinkaya E, Yaşar Z, Acat M.
diameter valve in apical and posterior segments, 5.5
mm diameter valve in anterior segment) placed to
stop the air leak (Figure 2). After the procedure his
health status was improved, he was decanulated and
discharged within 1 week. On 7-month follow up,
complete expansion of the lung was detected and no
pneumothorax was observed.
DISCUSSION
Figure 1. Chest imaging demonstrated a total pneumothorax in
the right lung.
Figure 2. Thoracic-computed tomography (CT), bullous areas
at the apexes of both lungs and a right pneumothorax were
observed.
contraindicated because of his healthy status. Because
of prolonged chest drainage causes prolonged hospital
stay and many complications; he discharged with
drain tube connected to a Heimlich valve. Two weeks
after hospital discharge until the patient could tolerate
the drain being clamped, negative aspiration and talc
pleurodesis were performed twice without satisfactory
results. Based on a published report, endobronchial
valve was attempted. Baloon catheter was inserted via
the working channel of the flexible bronchoscope
and balloon inflated on the right upper lobe. With
occlusion of the right upper lobe bronchus, the air
leak was ceased. 3 Zephyr valve were (4 mm
COPD is the common cause of spontaneous seconder
pneumothorax and the most consistently identified
risk factor for persistent air leak that is detected in
20% of COPD patients (1). Also it is reported in up to
45% of cases who have undergone lung volume
reduction surgery due to pulmonary emphysema (5).
Persistent air leak may cause a high level of mortality,
infectious, cardiopulmonary complications and
prolonged hospital stays (3,6). The treatment options
are thoracostomy drainage, pleurodesis, surgical
decortication, surgical repair, endobronchial valves.
Patients with underlying lung disease especially
COPD tend to have longer duration of air leaks. If it
is lasting longer than seven days surgery procedures
should be the first option. In COPD patients, surgical
risk is generally much increased like our case. These
patients present therapeutic adversities of carrying
prolonged chest drainage as increased risk of
infections, subcutaneous emphysema, misplacement
of the tube and prolonged hospital stays. One of the
alternative approach is medical pleurodesis but the
study in the literature showed that it has not yet been
very effective (7). Local radiotherapy was used in
patients with persistent pneumothorax controversial
results are reported in previous studies (4,8).
The other encouraging approach is endobronchial
treatment such as endobronchial valves (EBV) that
can be performed with flexible bronchoscope. EBV
prevents air from entering distal airways and allows
time for to heal. Traveline and colleagues reported
that the EBV was effective for a large number of
patients with persistent air leak (3). The previous
study showed the use of EBV in two complex medical
condition as lymphangiomyomatosis and severe
pneumonia with ARDS (9). Detection of air leaking
source is important for successful procedure. The
most commonly used method is balloon catheter
occlusion that inserted through the working channel
of bronchoscopy. Balloon inflated and assessed the
degree of air leak. The EBV is then deployed to the
leaking airways by use of delivering catheter.
Tuberk Toraks 2015;63(2):142-144
143
Treatment of persistent air leak with endobronchial valves: a case report
The adverse affects may occur in the treatment of
pulmonary emphysema with EBV. These complications
include pneumothorax, pneumonia of non-involved
lobes, COPD exacerbation and pleural effusion. In
our case we have not seen any of these complications
on 7 month follow-up.
We describe the case of a 63-year-old man who
presented with secondary spontaneous pneumothorax
and persistent air leak. Implantation of EBV decreased
the air leak enough for the chest tube to be removed.
These nonsurgical and minimally invasive approaches
that may promising for patients with persistent air
leak. However, prospective studies are needed to
observe the treatment results to validate this approach.
CONFLICT of INTEREST
None declared.
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Tuberk Toraks 2015;63(2):142-144
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