SESSION TITLE: Bronchology Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Persistent air leaks after pneumothorax are frequently encountered in patients with structural lung disease. For individuals with advanced medical comorbidities, treatment options are limited due to elevated risk associated with general anesthesia and surgical intervention. Interventions that involve pleurodesis have diminished efficacy in the setting of a compromised inflammatory response. One-way endobronchial valves have been effective for persistent post-operative air leaks with the advantage of a minimally-invasive approach. Typically, the valves are removed a few weeks after insertion and resolution of the air leak. However, in patients with underlying structural disease, a pneumothorax often returns, leading to repetitive hospitalizations and multiple procedures. Here we report the long-term placement of valves as destination therapy for the purpose of preventing such consequences.
CASE PRESENTATION: A 69 year-old man with acute myeloid leukemia refractory to several lines of chemotherapy and severe COPD was diagnosed with a right secondary spontaneous pneumothorax requiring chest tube placement. Five days later he continued to have a significant continuous air leak. CT-chest demonstrated apical bullae and superimposed fungal pneumonia. The interventional pulmonology and thoracic surgery team considered a number of therapeutic options including pleurodesis, video-assisted thoracic surgery with bullectomy, and apical pleurectomy all determined to be high-risk due to his compromised hematologic parameters, wound healing, and infection. Instead, we performed bronchoscopy and three endobronchial valves (IBV Valve®, Spiration) were placed into the right upper lobe apical sub-segments. The air leak promptly resolved and his chest tube was removed. Two months later, the valves were removed uneventfully, following the product's intended use guideline. Within three weeks he developed another right pneumothorax and persistent air leak. Valves were replaced in the right upper lobe apical sub-segments with the intent to remain as destination therapy. He has had no further pneumothoraces or complications related to the valves.
DISCUSSION: Endobronchial one-way valves are indicated for prolonged post-operative air leaks and removal within six weeks is recommended. However, in patients with structural lung disease and complex comorbidities that prohibit definitive intervention, recurrent pneumothoraces with persistent air leaks are likely. Such events are potentially life threatening and a source of morbidity requiring hospitalizations and uncomfortable procedures. Valves as destination therapy in these patients appears to be a safe and well-tolerated option.
CONCLUSIONS: In certain high-risk individuals with persistent air leaks after pneumothorax, one-way endobronchial valve placement as destination therapy may be a reasonable management strategy.
Reference #1: Travaline J et al. Treatment of pulmonary air leaks using endobronchial valves. CHEST 2009;136;355-60
DISCLOSURE: Jennifer Toth: Other: Educational consultants and clinical advisory board to Spiration, an Olympus subsidiary. Michael Reed: Other: Educational consultants and clinical advisory board to Spiration, an Olympus subsidiary. The following authors have nothing to disclose: Umar Osman, Christopher Gilbert
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