Procedures: Student/Resident Case Report Poster - Procedures |

Impossible to Deflate: A Minimally Invasive Approach to Bullous Emphysema and Recurrent Spontaneous Pneumothorax FREE TO VIEW

Nina Akbar, MD; Timothy Leclair, MD; Charles Kinsey, MD; Benjamin Suratt, MD
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Danbury Hospital, Danbury, CT

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1030A. doi:10.1016/j.chest.2016.08.1136
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SESSION TITLE: Student/Resident Case Report Poster - Procedures

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: One of the targets of emphysema treatment is optimizing airflow, whether by lung volume reduction surgery, bullectomy, transplantation, or through the minimally invasive application of one-way endobronchial valves (EBVs). We present a case highlighting further uses of EBVs to address anticipated complications such as spontaneous pneumothorax and bronchopleural fistula.

CASE PRESENTATION: A 66-year-old man with a prior 15-pack-year smoking history presented with worsening cough productive of white sputum and dyspnea upon awaking and with moderate exertion. Two months earlier, video assisted thoracoscopic surgery and right upper lobe wedge resection with blebectomy were performed after secondary spontaneous pneumothorax occurred in the setting of significant centrilobular and paraseptal emphysema. He returned with a multiloculated pneumothorax requiring computed tomography guided chest tube insertion and drainage. Flexible bronchoscopy under intubation revealed an accessory right tracheal bronchus two centimeters above the carina. A #7 Fogarty catheter with a balloon was used to serially occlude the accessory tracheal, right mainstem, right upper, right middle, right lower lobe and superior segmental bronchi without complete resolution of the air leak, suggesting the presence of a bronchopleural fistula with either multiple contributing or distal interconnecting airway sources, a common problem in emphysema. The decision was made to pursue EBV placement since decreasing axial airflow to the bronchopleural fistula can lead to subsequent closure. Deployment of two #7 intrabronchial valves (IBVs, Spiration, Redmond, WA) to the tracheal bronchus and the apical segment of the right upper lobe lessened the leak. By the time of discharge, four days after chest tube removal, chest x-ray demonstrated interval lung volume expansion. The patient had improved respiratory tolerance, exhibiting exertional dyspnea only after climbing one flight of stairs. After three months, he resumed his hobby of swimming, and spirometry showed no signs of obstruction.

DISCUSSION: Prior investigations of EBVs for select post-surgical candidates have encouraged alternate uses in the treatment of air leaks.1 Our case extends these efforts by confronting additional challenges not frequently encountered in these studies: redirecting airflow through strategic and innovative applications of EBVs in a patient with extensive bullous disease and uncommon anatomical lung variations, such as a tracheal bronchus and post-operative modifications.

CONCLUSIONS: Recurrent pneumothorax in bullous emphysematous lung disease is becoming more manageable with the therapeutic supplementation of EBVs to limit ineffective gas exchange.

Reference #1: Hance, J, et al. Endobronchial Valves in the Treatment of Persistent Air Leaks. Ann Thorac Surg. 2015; 100:1780-86.

DISCLOSURE: Charles Kinsey: Grant monies (from industry related sources): UVM primary investigator for the EMPROVE trial The following authors have nothing to disclose: Nina Akbar, Timothy Leclair, Benjamin Suratt

Dr. Kinsey is the on-site primary investigator at the University of Vermont Medical Center for the EMPROVE trial. The use of Spiration valves carries a humanitarian device exemption for post-operative air leaks. This case presents the off-label use of the device as a part of a collective research effort.




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