Bronchoscopic valve placement is currently under investigation as a non-surgical means of lung volume reduction for the treatment of emphysema. This is a case of hemoptysis one month after 5 valves were placed to exclude the right lower lobe.
Sixty-four year old female with emphysema was randomized to valve placement and treated according to the research protocol. The lung parenchyma was scored by CT scan and the right lower lobe was selected as the optimal lobe for lung volume reduction. Five valves were needed to exclude the right lower lobe and were placed in B6-B10 respectively. All valves were placed with their most proximal portion being centered within the airway as shown in the figure below. The patient was discharged home on day two without complication. One month later, the patient presented with intermittent, scant, bright red hemoptysis for 2 days without dyspnea, epistaxis, fevers, lower extremity swelling, or chest pain. Oxygenation on room air was improved compared to her pre-valve evaluation. CT scan with intravenous contrast showed partial lower lobe collapse but was otherwise non-diagnostic. Bronchoscopy revealed that the proximal portion of the valve placed in B7 (medial basal segment) had eroded into the opposite endobronchial wall, as shown in the figure below, causing hemoptysis . Some airway inflammation localized to the area of the valve was appreciated. No intervention was employed as some epithelialization of the valve was evident and in our opinion the risks of bleeding and damage to the airway outweighed the benefits of removal. A first generation cephalosporin was given in conjunction with 40 mg of prednisone daily for ten days. No active bleeding was evident at bronchoscopy and she has not had any hemoptysis or worsening dyspnea two months after the described episode. Based on our experience with metal stents, a follow up bronchoscopy was planned for 90 days post-hemoptysis in hopes that epithelialization would be complete as well as resolution of the inflammation preventing the valve from coming into contact with the opposite bronchial wall.
The endobronchial valves used in this patient are essentially specialized silicone covered nitinol stents and will likely have the same issues that other nitinol stents possess including bleeding, granulation tissue formation, and airway stenosis. Endobronchial valve placement is a safe procedure however, this case suggests that a combination of airway inflammation and any lobar collapse could potentially change the anatomy in such a way as to allow a valve to erode into the opposite wall of the bronchous causing hemoptysis. This could possibly be prevented by placing the valves more distal within the bronchus having thier opening flush to the bronchial opening.
Endobronchial valve placement for lung volume reduction has the potential to provide palliation to a population that have few options for the treatment of their dyspnea however, hemoptysis caused by the endobronchial valves will require long term follow up to determine if this is a reproducible phenomena.
Simrit Bhular, Grant monies (from industry related sources) Emphasys Medical, Inc., Redwood City, CA