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* From the Divisions of Pulmonary, Allergy and Critical Care Medicine (Drs. Crespo, Johnson, and Sciurba) and Cardiothoracic Surgery (Drs. McCurry and Landreneau).University of Pittsburgh, Pittsburgh, PA.
Correspondence to: Maria M. Crespo, MD, University of Pittsburgh Medical Center, Division of Pulmonary, Allergy and, Critical Care Medicine, NW 628 Montefiore University Hospital, 3459 Fifth Ave, Pittsburgh, PA 15213; e-mail: crespomm{at}upmc.edu
Abstract
Emphysema is a common indication for adult pulmonary transplantation. Double-lung transplantation is increasingly the preferred approach because severe posttransplant native lung hyperinflation (NLH) following single-lung transplantation may compromise allograft lung function. We describe successful emergency use of bronchoscopic lung volume reduction using endobronchial valves (EBVs) [Zephyr; Emphasys Medical; Redwood, CA] in a single-lung transplant recipient who was critically ill with ventilator dependence from complications of NLH and at excessive risk for lung volume reduction surgery or pneumonectomy. Following placement of 17 valves in all segments of the native lung, atelectasis of the native lung was accompanied by volume expansion of the allograft. Immediately following valve placement, peak airway pressure decreased and alveolar ventilation increased. The patient was subsequently weaned from mechanical ventilation. This report suggests the need for clinical trials to evaluate the effectiveness of EBVs in single-lung transplant recipients with less critical functional impairment associated with NLH.
Key Words: bronchoscopy • emphysema • endobronchial valve • lung transplant • native lung hyperinflation • volume reduction
Emphysema is a common indication for adult pulmonary transplantation. Double-lung transplantation is increasingly the preferred approach because severe posttransplant native lung hyperinflation (NLH) following single-lung transplantation may compromise allograft lung function.1,2 We report successful bronchoscopic lung volume reduction (BLVR) in a single-lung transplant recipient with emphysema resulting in resolution of severe lung NLH and respiratory failure.3
Case Report
A 60-year-old man with a history of emphysema due to 
1-antitrypsin deficiency underwent right single-lung transplantation 7 years prior to presentation. His posttransplant course was not significant for infection or chronic rejection. His lung function had been stable for 5 years; his last spirometry (FEV1, 56% of predicted; FVC, 54% of predicted) was performed 6 months prior to hospital admission. Immunosuppression included tacrolimus and azathioprine without prednisone, and enzyme-replacement therapy with prolastin was continued. Chest radiography demonstrated NLH with a mediastinal shift.
He presented to his local hospital with sudden-onset respiratory failure requiring mechanical ventilation and was started empirically on broad-spectrum antibiotics for an infiltrate in the native left lung base. Echocardiography showed normal biventricular function and moderate pulmonary hypertension. Ultrasound studies showed a left leg deep vein thrombosis, and an inferior vena cava filter was placed when intractable hemoptysis required discontinuation of IV heparin. Three weeks following hospital admission, he was transferred to our facility due to refractory ventilator dependence and hemoptysis. Chest CT scan revealed NLH associated with mediastinal shift and volume loss in the allograft (Fig 1 , top, A; Table 1 ) and a left lower lobe infiltrate. Bronchoscopy identified active bleeding from the native left lower lobe without endobronchial lesions. Transbronchial biopsies from the allograft indicated minimal rejection without infection. Allograft BAL, native lung bronchial washings, and blood culture results were consistently sterile. 99mTc-macroaggregated albumin perfusion scanning demonstrated no significant focal defects with 73% of perfusion to the allograft.
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The Food and Drug Administration and our institutional review board were petitioned for emergency use of one-way endobronchial valves (EBVs) [Zephyr; Emphasys Medical; Redwood, CA) to treat the severe NLH. The valves consist of a silicon-coated, self-expanding nitinol retainer supporting a unidirectional silicone flap valve. Seventeen valves (standard size, 5 to 7 mm) were placed in all segments of the native left lung through the channel of a 3.1-mm fiberoptic bronchoscope under general anesthesia. Visual atelectasis was confirmed by quantitative CT analyses demonstrating decreases in volume of the native left lung and increase in allograft volume (Fig 1; Table 1). Furthermore, the native lung air leak stopped immediately, and hemoptysis gradually resolved. Ventilatory and gas exchange data shown in Table 2 reveal decreased peak airway pressures associated with improved alveolar ventilation. The patient began effective weaning trials within 1 week of valve placement and was discontinued from positive pressure ventilation within 5 weeks of valve placement, whereupon he was accepted for transfer to an outside rehabilitation center.
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NHL associated with impairment in allograft function after single-lung transplantation for emphysema is a frequent problem. Prior reports of lung volume reduction surgery of the native lung for this condition suggest significant morbidity.4,5 We report successful BLVR in a single-lung transplant recipient with emphysema resulting in resolution of severe lung NLH and respiratory failure. Also noteworthy in this case, valve placement further resulted in successful resolution of bronchopleural fistula and hemoptysis.
BLVR in the context of single-lung transplantation may not be associated with factors inhibiting optimal response in traditional emphysema patients. First, when complete native lung occlusion is performed, as in our patient; collateral ventilation preventing effective volume reduction in the occluded segments should not be an issue. Furthermore, the presence of a well-functioning allograft to reexpand after decompression of NLH should have mechanical advantages beyond what is seen when residual emphysema is present in the nonoccluded lung.
While we demonstrated successful treatment of one patient, the risks, benefits, and patient selection factors in this heterogeneous group of individuals remain to be determined. Infectious complications, which were not observed in our case, must be closely monitored in future applications. Additionally, discrimination between allograft compression from NLH and volume loss associated with obliterative bronchiolitis must be considered. However, an important positive feature of BLVR is that is potentially reversible. We propose a systematic phase I trial evaluation of this approach in a less morbid group of single-lung transplant patients.
Footnotes
Abbreviations: BLVR = bronchoscopic lung volume reduction; EBV = endobronchial valve; NLH = native lung hyperinflation
Drs. Crespo, Landreneau, and Sciurba are investigators in the Endobronchial Valve for Emphysema Palliation Trial (Emphasys Medical, Inc). Drs. Johnson and McCurry have no conflicts of interest to disclose.
Received for publication May 4, 2006. Accepted for publication July 7, 2006.
References
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