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(Chest. 2006;129:479-481.)
© 2006 American College of Chest Physicians

Closure of a Bronchopleural Fistula Using Bronchoscopic Placement of an Endobronchial Valve Designed for the Treatment of Emphysema*

J. Scott Ferguson, MD, FCCP; Kimberly Sprenger, BSN and Timothy Van Natta, MD

* From Carver College of Medicine, Departments of Internal Medicine (Dr. Ferguson and Ms. Sprenger) and Thoracic and Cardiovascular Surgery (Dr. Van Natta), University of Iowa, Iowa City, IA.

Correspondence to: J. Scott Ferguson, MD, Department of Internal Medicine, C-33 GH 200, Hawkins Dr, Iowa City, IA 52242; e-mail: john-s-ferguson{at}uiowa.edu


   Abstract
TOP
 Abstract
Introduction
 Case Report
 Discussion
 Conclusion
 References
 
Pneumothoraces are sometimes complicated by a persistent air leak or bronchopleural fistula requiring prolonged chest tube drainage. Non-surgical treatment of persistent bronchopleural fistulas is often performed in patients who are poor surgical candidates, but the ideal method of closure is not known. Here we report closure of a persistent distal bronchopleural fistula using a one-way endobronchial valve designed for the treatment of emphysema.

Key Words: bronchial fistula • bronchoscopy • pneumothorax


   Introduction
TOP
 Abstract
 Introduction
Case Report
 Discussion
 Conclusion
 References
 
Pneumothoraces are sometimes complicated by a persistent air leak or bronchopleural fistula (BPF) requiring prolonged chest tube drainage. It is generally recommended that surgical treatment be undertaken when possible. However, many patients are very poor surgical candidates. In this article, we report the successful closure of a prolonged air leak with a one-way endobronchial valve originally designed for the palliative treatment of emphysema.


   Case Report
TOP
 Abstract
 Introduction
 Case Report
Discussion
 Conclusion
 References
 
A 63-year-old man with widely metastatic breast cancer was admitted for sudden onset of severe dyspnea 8 days after thoracoscopic placement of an indwelling cuffed pleural catheter. A large hydropneumothorax was discovered, and the indwelling catheter was connected to suction, relieving the dyspnea. A chest tube was then placed and connected to a water-seal device. A large air leak was noted with each exhalation and continued for the next 9 days. A new chest tube was placed, but the air leak continued.

The etiology of the pneumothorax was not certain but was assumed to be a delayed complication of the thoracoscopy, as opposed to necrosis and breakdown of a metastatic focus of tumor. A thin-section, multidetector CT scan of the chest revealed multiple metastases, hydropneumothorax, and airspace disease of the lower lobes. No radiographic evidence of BPF was present.

Surgical correction with plication of the offending lobe was considered but judged to be risky given that the patient’s pulmonary reserve was limited due to the metastatic disease. Endoscopic therapies with glue, gel foam, and coiling were considered but were judged to have a low likelihood of success based on the endoscopist’s previous experience with these methods in other patients. Therefore, these techniques of BPF closure were not attempted in this patient.

One-way endobronchial valves for the treatment of emphysema became available in the United States last year as part of a national clinical trial.1 We thought placement of an endobronchial valve that would allow escape of air from the offending segment or lobe, but block air entry, may be useful as a minimally invasive technique to control the BPF. A compassionate use protocol was approved by the University of Iowa Internal Review Board, the Food and Drug Administration, and the maker of the valve (Emphasys Medical; Redwood City, CA).

After informed consent, the patient was brought to the operating room. The right-sided chest tube on water seal was observed to bubble with each breath. A general anesthetic was used so that there was good control of ventilation and cough during the procedure. Anesthesia was induced, and the patient was intubated with a large (size 9.0) endotracheal tube to reduce the need for high airway pressures during bronchoscopy and manual ventilation.

Flexible bronchoscopy was performed, and the segmental airway anatomy was examined. No abnormalities were noted other that mild inflammation. A 5F Fogarty catheter was passed through the working channel of the bronchoscope, and the lobar bronchi were sequentially occluded each for at least 10 respiratory cycles. The air leak did not diminish with occlusion of the upper and lower lobe bronchi but completely ceased when the right middle lobe bronchus was occluded. There was prompt return of the air leak on deflation of the balloon. The balloon was then used to occlude the segmental airways of the right middle lobe (RML), but only a partial reduction in the air leak was observed with occlusion of the lateral and medial segments. This process was repeated for confirmation with exactly the same results.

A 4.0-mm, expandable (designed for a 4.0- to 7-mm diameter bronchus) one-way endobronchial valve (Zephyr Valve; Emphasys Medical) was placed into the RML bronchus (Fig 1 ) through the bronchoscope according to the instructions supplied with the valve. Briefly, the valve was loaded into a flexible delivery catheter that is fitted with flexible 7.0-mm and 4.0-mm radial bronchial diameter guides positioned 15 mm from the distal tip of the device. These guides are used to size the airway for proper placement. When the delivery device is placed into the target airway, the appropriate sized airway walls will contact the 7.0-mm guides while not touching the 4.0-mm guides. The delivery device was passed through the working channel of the bronchoscope and directed into the RML bronchus. After confirming that the RML bronchus measured approximately 6.0 mm as judged by visualization of the radial guides, the valve was deployed into the bronchus and positioned to occlude both the lateral and medial segmental airways. There was immediate cessation of air leakage through the chest tube. After the endobronchial valve was placed, sustained positive airway pressures of 20 cm and then 30 cm of water did not result in air leak from the chest tube (go online at www.chestnet.org to view a videotape of the procedure).


Figure 1
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  		Figure 1.. Endobronchial valve in the RML bronchus.

 
The chest tube was removed the next day after resolution of the hydropneumothorax, and the patient was discharged. Four months after the procedure, the patient has done well with therapy for his disease and has had no recurrence of the pneumothorax. The valve has remained in place, and no attempts at removal have been made. The pleural effusion has remained small, likely as a result of systemic chemotherapy.


   Discussion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
Conclusion
 References
 
Persistent air leaks or BPF after pneumothorax or chest surgery are the subject of many case reports, indicating that the optimal therapy is not known. Drainage of the pleural space, treatment of infections, and optimizing nutrition are the mainstays of conservative management. If the BPF fails to close, several surgical methods of closure have been published,2 but many patients are not able to tolerate further or initial thoracic surgery. Endoscopic closure has gained in popularity since this is a minimally invasive technique that tenuous patients are more apt to tolerate.

Multiple methods of closure via the bronchoscope are reported in the literature including gel foam, fibrin sealant, methylmethacrylate, injection of absolute ethanol, endobronchial silicone plugs, albumin gluteraldehyde tissue adhesive, decalcified bone, and lead plugs.3456 Success with any of these methods is likely to be dependent on the patient receiving treatment as well as the skill of the bronchoscopist.

In this report, we describe a unique method of BPF closure using an endobronchial valve that was designed for the palliative treatment of emphysema and is currently in clinical trails across the United States and Europe.1 The valve is made of a central silicone core that is fashioned to drain air and secretions from the distal lung segment, while blocking entry of air, resulting in redirection of airflow away from diseased segments and, in some cases, collapse of the diseased segment and expansion of the more normal adjacent lung. The core is surrounded by a nitinol expandable mesh that anchors the valve within the bronchus. The valve is inserted through the working channel of the bronchoscope using a guided insertion device provided by the manufacturer. Although the valve is designed to be permanent, it can be removed bronchoscopically with little difficulty. Because of its design, we speculated that the valve could be a potential treatment of distal (not endoscopically visible) BPF.

A key point of the procedure was to accurately identify the particular bronchus involved in the BPF. Sequential balloon occlusion of the lobar and segmental airways accurately identified the BPF as located in the RML. Sequential occlusion of the RML segments reduced the leak to an estimated 50% of the total, but complete cessation of the leak was only obtained when the lobar bronchus was occluded. Therefore, a single valve was placed into the RML bronchus and closure of the BPF was obtained. The valve is not likely to be useful in proximal, large (bronchoscopically visible) postsurgical BPF, since in this type of fistula the location is often within a surgical stump, and there is the concern that the valve would migrate into the pleural space potentially creating additional complications.


   Conclusion
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 Conclusion
References
 
We believe that using an endobronchial valve to close a BPF has advantages over the other methods published for the following reasons: (1) the valve is relatively straightforward to place once the bronchoscopist is trained; (2) the valve is easily removed if there is a clinical indication that it should be; (3) occlusion of nontargeted segments is likely to be nonexistent; (4) dislodgement is rare; and (5) the relative position of the device can be assessed at follow-up using radiography.


   Footnotes
 
Abbreviations: BPF = bronchopleural fistula; RML = right middle lobe

Dr. Ferguson, Ms. Sprenger, and Dr. Van Natta were supported in part by the Endobronchial Valve for Emphysema Palliation Trial (VENT) Trial.

Received for publication August 31, 2005. Accepted for publication October 1, 2005.


   References
TOP
 Abstract
 Introduction
 Case Report
 Discussion
 Conclusion
 References
 

  1. Brenner, M, Hanna, NM, Mina-Araghi, R, et al (2004) Innovative approaches to lung volume reduction for emphysema. Chest 126,238-248[Abstract/Free Full Text]
  2. Steiger, Z, Wilson, RF Management of bronchopleural fistulas. Surg Gynecol Obstet 1984;158,267-271[ISI][Medline]
  3. Varoli, F, Roviaro, G, Grignani, F, et al Endoscopic treatment of bronchopleural fistulas. Ann Thorac Surg 1998;65,807-809[Abstract/Free Full Text]
  4. Lin, J, Iannettoni, MD Closure of bronchopleural fistulas using albumin-glutaraldehyde tissue adhesive. Ann Thorac Surg 2004;77,326-328[Abstract/Free Full Text]
  5. Watanabe, S, Watanabe, T, Urayama, H Endobronchial occlusion method of bronchopleural fistula with metallic coils and glue. Thorac Cardiovasc Surg 2003;51,106-108[CrossRef][ISI][Medline]
  6. Ponn, RB, D’Agostino, RS, Stern, H, et al Treatment of peripheral bronchopleural fistulas with endobronchial occlusion coils. Ann Thorac Surg 1993;56,1343-1347[Abstract]



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