Pulmonary Procedures |

The Importance of Clinical Judgment in Placement and Removal of Endobronchial Valves (EBV): A Case Series FREE TO VIEW

Haroon Raja, MD; Dany Gaspard, MD; Rohan Arya, MD; Ziad Boujaoude, MD; Wissam Abouzgheib, MD
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Cooper University Hospital, Cherry Hill, NJ

Chest. 2015;148(4_MeetingAbstracts):829A. doi:10.1378/chest.2281265
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SESSION TITLE: Procedures Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: We discuss 4 cases in which clinical judgment illustrates innovative management in EBV use.

CASE PRESENTATION: A 46 year old (YO) male presented with a persistent air leak from right middle lobe (RML) angio-invasive aspergillus as seen on chest computed tomography (CT). Proximal to distal balloon occlusion did not stop the leak. Radiographic suspicion led to EBV occlusion of the RML with leak improvement. After leak recurrence, 2 additional EBVs placed in the upper lobes completely resolved it (fig 1). A tortuous right main bronchus and collateral ventilation were likely reasons for the initial failed balloon occlusion maneuver. A 66 YO female presented with an air leak following a right lower lobe lobectomy. Balloon occlusion did not localize the leak and no stump abnormality was seen. Review of the CT showed an air bubble distal to the stump. EBV placement in the surgical stump led to successful air leak cessation (fig 2). A 55 YO male presented with an air leak following surgical decortication. Radiographic evidence of a broncho-pleural fistula led to successful EBV placement. At the 6 week and 6 month follow up, chest CT showed an airway directly communicating with the pleura. The EBVs were intentionally left in place. A 57 YO male presented with a persistent air leak following a VATS for bullous lung disease. Repeated EBV placements only briefly stopped the leak. Review of the CT showed migration of the chest tube into an apical bulla. Chest tube removal led to leak resolution.

DISCUSSION: Determination of the culprit airway for a prolonged air leak is achieved by proximal to distal balloon occlusion during planned EBV placement. We present several cases with failed balloon occlusion maneuvers. In cases with high clinical and radiographic suspicion, targeted EBV placement followed by balloon occlusion of neighboring lobes may lead to leak resolution. Inability to obtain complete balloon occlusion and leak cessation may be due to anatomic variability or airway tortuosity. In cases of recurring leaks after successful EBV placement, other factors to consider are migration of a chest tube into a bulla or outside the chest cavity. Repeat imaging is unnecessary prior to EBV removal, however may be beneficial in cases with suspected persistent broncho-pleural fistula.

CONCLUSIONS: Clinical jugdement and radiographic imaging play a vital role in management of EBVs.

Reference #1: AK. Mahajan, et al. Isolation of persistent air leaks and placement of intrabronchial valves. J Thorac Cardiovasc Surg. 2013 Mar; 145(3): 10.101

DISCLOSURE: The following authors have nothing to disclose: Haroon Raja, Dany Gaspard, Rohan Arya, Ziad Boujaoude, Wissam Abouzgheib

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