Endobronchial Valve Management of a Persistent Air Leak Complicating Bullous Emphysema

Abstract SESSION TYPE: Bronchology Student/Resident Case Report PostersPRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PMINTRODUCTION: The frequency of secondary spontaneous pneumothorax (SSP) varies according to the underlying lung disease, and is commonly seen with lymphangioleiomyomatosis but also occurs in COPD. Spontaneous closure of air leaks significantly decline after 5-7 days and surgical management is the standard of care for correcting a persistent air leak. However, co-morbid conditions, severe architectural distortion of the underlying lung parenchyma, and the severity of the underlying lung disease often dissuade surgeons in pursuing corrective surgical options. Endobronchial occlusion with one-way valves is an attractive option when a persistent air leak occurs.CASE PRESENTATION: A 63-year-old white male with a history significant for GOLD IV COPD (FEV1 of 0.37L) presented to the emergency department with respiratory distress requiring intubation. Chest x-ray revealed a right-sided pneumothorax and a chest tube was placed with subsequent re-expansion of the lung. A repeat chest x-ray showed a small residual apical pneumothorax with no air-leak in the chest tube. He was extubated the following morning, but developed hypercapneic respiratory failure and was re-intubated. He was found to have a worsening pneumothorax on the right despite the chest tube, so a second chest tube was placed. The lung adequately re-expanded and he was extubated. However the second chest tube had a persistent and continuous air-leak 5 days after the second chest tube was placed. Cardiothoracic surgery was consulted due to the persistent air leak, but declined operative repair secondary to his poor baseline lung function. The patient was also unable to undergo pleurodesis because he could not tolerate clamping of his chest tube. After maximal medical management, he was transferred to a rehabilation facility with his chest tube on suction. Four days later, he underwent endobronchial valve placement in the right upper lobe (using 5 valves) to slow the air leak. The patient was successfully underwent a talc pleurodesis the following day. He was discharged home with a hemlich valve due to an occasional leak. The chest tube was removed 4 weeks later without complications. The endobronchial valves were not removed due to the terminal stage of his emphysema.DISCUSSION: Persistent air leaks complicating bullous emphysema are problematic. Surgical options should be considered first; however, due to numerous complicating factors, surgical options may not be feasible.CONCLUSIONS: The therapeutic role of endobronchial valves in managing SSP remains to be defined with future studies, but clearly have a role in selected patients with persistent air leaks.1) Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of Spontaneous Pneumothorax: An American College of Chest Physicians Delphi Consensus Statement. CHEST 2001;119;590-602.DISCLOSURE: The following authors have nothing to disclose: Philip Svigals, Luca Paoletti, Nicholas Pastis, John HugginsNo Product/Research Disclosure InformationMedical University of South Carolina, Charleston, SC.