Bronchoscopic management of prolonged air leak

Abstract

Bronchopleural fistula (BPF) with prolonged air leak (PAL) is most often, though not always, a sequela of lung resection. When this complication occurs post-operatively, it is associated with substantial morbidity and mortality. Surgical closure of the defect is considered the definitive approach to controlling the source of the leak, but many patients with this condition are suboptimal operative candidates. Therefore there has been active interest for decades in the development of effective endoscopic management options. Successful use of numerous bronchoscopic techniques has been reported in the literature largely in the form of retrospective series and, at best, small prospective trials. In general, these modalities fall into one of two broad categories: implantation of a device or administration of a chemical agent. Closure rates are high in published reports, but the studies are limited by their small size and multiple sources of bias. The endoscopic procedure currently undergoing the most systematic investigation is the placement of endobronchial valves. The aim of this review is to present a concise discussion on the subject of PAL and summarize the described bronchoscopic approaches to its management.

Keywords: Air leak; bronchial valves; bronchopleural fistula (BPF); bronchoscopy; pneumothorax.

Figure 1

CT chest showing a communication between a peripheral branch of the right middle lobe medial segment bronchus and the pleural space (arrow) in a patient with a BPF due to erosive lung cancer.

Figure 2

^99mTc-DTPA ventilation scintigraphy image showing focal radiotracer accumulation in the lower left hemithorax (arrow) corresponding to the site of PAL in a patient with left secondary spontaneous pneumothorax in the setting of idiopathic pulmonary fibrosis.

Figure 3

Diagram of the Spiration^® endobronchial valve. Image courtesy of Olympus Respiratory.

Figure 4

Depiction of the Zephyr^® endobronchial valve. Image courtesy of Pulmonx, Inc.

Figure 5

Appearance of the Spiration^® endobronchial valve in the proximal right middle lobe bronchus as viewed from the bronchus intermedius. Image courtesy of Dr. Kassem Harris.

Figure 6

Three sizes of endobronchial Watanabe spigots (EWS^®). Image courtesy of Novatech.

Figure 7

Appearance of Coseal^® upon instillation into a lobar bronchus as it begins to congeal into a plug. Image courtesy of Dr. Kassem Harris.

Figure 8

An example of an Amplatzer occluder: AMPLATZER^® Duct Occluder II. Image courtesy of St. Jude Medical.