[Skip to Navigation]
Sign In
Table 1.  Patient Demographic and Procedural Characteristics
Patient Demographic and Procedural Characteristics
Table 2.  Characteristics of Air Leak, Drainage, and Hospital Stay
Characteristics of Air Leak, Drainage, and Hospital Stay
1.
Gillespie  CT, Sterman  DH, Cerfolio  RJ,  et al.  Endobronchial valve treatment for prolonged air leaks of the lung: a case series.  Ann Thorac Surg. 2011;91(1):270-273.PubMedGoogle ScholarCrossref
2.
Travaline  JM, McKenna  RJ  Jr, De Giacomo  T,  et al; Endobronchial Valve for Persistent Air Leak Group.  Treatment of persistent pulmonary air leaks using endobronchial valves.  Chest. 2009;136(2):355-360.PubMedGoogle ScholarCrossref
3.
Firlinger  I, Stubenberger  E, Müller  MR, Burghuber  OC, Valipour  A.  Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring.  Ann Thorac Surg. 2013;95(4):1243-1249.PubMedGoogle ScholarCrossref
4.
Vial  MR, Lan  C, Cornwell  L, Omer  S, Casal  RF.  Endobronchial oxygen insufflation: a novel technique for localization of occult bronchopleural fistulas.  Ann Am Thorac Soc. 2013;10(2):157-159.PubMedGoogle ScholarCrossref
5.
Gilbert  CR, Casal  RF, Lee  HJ,  et al.  Use of one-way intrabronchial valves in air leak management after tube thoracostomy drainage.  Ann Thorac Surg. 2016;101(5):1891-1896.PubMedGoogle ScholarCrossref
6.
Spiration Valves Against Standard Therapy (VAST). https://clinicaltrials.gov/ct2/show/NCT02382614?term=spiration&rank=1. Accessed April 18, 2016.
Research Letter
Association of VA Surgeons
February 2017

Bronchoscopic Management of Prolonged Air Leaks With Endobronchial Valves in a Veteran Population

Author Affiliations
  • 1The Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas
  • 2Cleveland Clinic, Cleveland, Ohio
JAMA Surg. 2017;152(2):207-209. doi:10.1001/jamasurg.2016.3195

Prolonged air leak (PAL) poses a therapeutic dilemma and can entail morbidity, prolonged hospitalization, increased health care costs, and mortality. Common therapeutic options—including prolonged thoracotomy tube drainage, pleurodesis, autologous blood patch, and attempted surgical repair—are often ineffective and can sometimes even exacerbate the problem. Bronchoscopic management of air leaks with endobronchial valves (EBVs) has become an attractive minimally invasive alternative treatment.1-3 The aim of our study was to analyze the effectiveness and safety of EBVs in a high-risk veteran population.

Methods

We retrospectively reviewed the medical records of patients undergoing bronchoscopic EBV insertion for PAL (>5 days) in our institution from 2012 through 2015. Institutional review board approval was obtained from the Michael E. DeBakey VA Medical Center, Baylor College of Medicine; patient consent was waived because of this study’s retrospective nature. Endobronchial valve placement was performed under general anesthesia. The source of leakage was localized with balloon occlusion and/or endobronchial oxygen insufflation,4 and digital monitoring of air leak was used.

Results

Fifteen patients met our inclusion criteria; all were male veterans with a history of smoking. Comorbidities included current smoking (n = 7; 47%), chronic obstructive pulmonary disease (n = 12; 80%), and lung carcinoma (n = 9; 60%) (Table 1). The mean (SD) American Society of Anesthesiologists score was 3.1 (0.3). The etiology of air leak was lung surgery (n = 6; 40%), secondary spontaneous pneumothorax (n = 4; 27%), iatrogenic pneumothorax (n = 4; 27%), and traumatic pneumothorax (n = 1; 6.7%).

Table 2 shows the results. The mean number of valves inserted was 3.87. Median time to air-leak resolution was 2 days (interquartile range, 0.5-5.5). Within 48 hours after EBV placement, the leaks were completely resolved in 10 patients (67%). Of 12 patients (80%) who were dependent on chest-tube suction before valve placement, 11 (92%) were switched to water-seal immediately after valve implantation. Of 13 patients who had a pneumothorax or subcutaneous emphysema on chest radiography, 8 (62%) showed significant improvement immediately after valve placement.

There were no deaths or serious complications. Minor complications included self-resolving atelectasis in 1 patient and dyspnea requiring partial removal of EBVs in another patient. Eleven patients underwent valve removal within 2 months. Two patients were lost to follow-up, and 2 others chose to keep the valves in place because of perceived improvement in breathing capacity.

Discussion

To our knowledge, use of EBVs for PAL in a high-risk veteran cohort has not previously been reported. Despite high American Society of Anesthesiologists scores and multiple severe comorbidities, our patients tolerated the procedures well; in two-thirds of the cases, the air leaks resolved within 2 days after valve implantation.

Several small case series involving nonveterans have shown the efficacy of EBVs in treating PAL, which may have a substantial effect on the hospital length of stay.1-3 Our results corroborate these findings in our veteran population. Of note, EBVs appear to be most effectively used in severe and prolonged air leaks, such as those of our patients, 80% of whom were dependent on suction, but yet responded well to EBV treatment. A large multicenter case series involving EBV use was recently published.5 That study was not limited to patients with PAL, in whom we believe EBVs may be most beneficial. In fact, the valves were implanted as early as 24 hours from the leak’s onset. Hence, the results cannot be easily compared with ours or with those of prior series.

Limitations of our study include its retrospective nature, small sample size, and lack of a control group. However, the avoidance of serious complications and the median time of only 2 days to leak resolution demonstrates the safety and effectiveness of EBVs in our series. We hope that the randomized clinical Spiration Valves Against Standard Therapy Trial6 will corroborate our findings.

Despite the heightened rate of comorbidities in the veteran population, EBVs appear to be a safe, effective, minimally invasive intervention for treatment of PAL.

Back to top
Article Information

Corresponding Author: Lorraine D. Cornwell, MD, The Michael E. DeBakey VA Medical Center, Baylor College of Medicine, 2002 Holcombe Blvd, OCL 112, Houston, TX 77030 (cornwell@bcm.edu).

Published Online: November 2, 2016. doi:10.1001/jamasurg.2016.3195

Author Contributions: Dr Cornwell had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Cornwell, Bakaeen, Preventza, Lazarus, Casal.

Acquisition, analysis, or interpretation of data: Cornwell, Panchal, Omer, Lazarus, Casal.

Drafting of the manuscript: Cornwell, Panchal.

Critical revision of the manuscript for important intellectual content: Cornwell, Bakaeen, Omer, Preventza, Lazarus, Casal.

Statistical analysis: Cornwell, Panchal.

Administrative, technical, or material support: Cornwell, Omer, Lazarus, Casal.

Study supervision: Cornwell, Preventza, Casal.

Conflict of Interest Disclosures: Drs Cornwell and Casal have received research funding from Spiration in the past. The current study was not sponsored by Spiration; hence, Spiration had no involvement in the current study. No other disclosures were reported.

Previous Presentation: This study was presented at the Association of VA Surgeons Annual Meeting; April 10-12, 2016; Virginia Beach, Virginia.

Additional Contributions: Virginia Fairchild, BA, of the section of Scientific Publications at the Texas Heart Institute, contributed to the editing of this work. Ms Fairchild was compensated as an employee of the Texas Heart Institute.

References
1.
Gillespie  CT, Sterman  DH, Cerfolio  RJ,  et al.  Endobronchial valve treatment for prolonged air leaks of the lung: a case series.  Ann Thorac Surg. 2011;91(1):270-273.PubMedGoogle ScholarCrossref
2.
Travaline  JM, McKenna  RJ  Jr, De Giacomo  T,  et al; Endobronchial Valve for Persistent Air Leak Group.  Treatment of persistent pulmonary air leaks using endobronchial valves.  Chest. 2009;136(2):355-360.PubMedGoogle ScholarCrossref
3.
Firlinger  I, Stubenberger  E, Müller  MR, Burghuber  OC, Valipour  A.  Endoscopic one-way valve implantation in patients with prolonged air leak and the use of digital air leak monitoring.  Ann Thorac Surg. 2013;95(4):1243-1249.PubMedGoogle ScholarCrossref
4.
Vial  MR, Lan  C, Cornwell  L, Omer  S, Casal  RF.  Endobronchial oxygen insufflation: a novel technique for localization of occult bronchopleural fistulas.  Ann Am Thorac Soc. 2013;10(2):157-159.PubMedGoogle ScholarCrossref
5.
Gilbert  CR, Casal  RF, Lee  HJ,  et al.  Use of one-way intrabronchial valves in air leak management after tube thoracostomy drainage.  Ann Thorac Surg. 2016;101(5):1891-1896.PubMedGoogle ScholarCrossref
6.
Spiration Valves Against Standard Therapy (VAST). https://clinicaltrials.gov/ct2/show/NCT02382614?term=spiration&rank=1. Accessed April 18, 2016.
×