Complications related to endoscopic lung volume reduction for emphysema with endobronchial valves: results of a multicenter study

Abstract

Background: Despite bronchoscopic lung volume reduction (BLVR) with valves is a minimally invasive treatment for emphysema, it can associate with some complications. We aimed at evaluating the rate and type of complications related to valve treatment and their impact on clinical outcomes.

Methods: It is a retrospective multicenter study including all consecutive patients with severe heterogeneous emphysema undergoing BLVR with endobronchial valve treatment and developed any complications related to this procedure. The type of complication, the time of onset, the treatment required and the out-come were evaluated. Response to treatment was assessed according to the minimal clinically important difference (MCID) as follows: an improvement of ≥15% in forced expiratory volume in one second (FEV₁); of -8% in residual volume (RV); of ≥26 m in 6-minnute walking distance (6MWD); and of ≥4 points on the St. George's Respiratory Questionnaire (SGRQ). Target lobe volume reduction (TLVR) ≥350 mL was considered significant.

Results: One hundred and seven out of 423 (25.3%) treated patients had complications related to valve treatment including pneumothorax (17.3%); pneumonia (1.7%), chronic obstructive pulmonary disease (COPD) exacerbation (0.9%), respiratory failure (1.4%), valve migration (2.1%), and hemoptysis (1.9%). In all cases complications resolved with appropriate treatment including removal of valves in 21/107 cases (19.6%). Patients with TLVR ≥350 mL (n=64) vs. those <350 mL (n=43) had a statistically significant higher improvement in FEV₁ (19.0%±3.9% vs. 3.0%±0.9%; P=0.0003); in RV (-10.0%±4.8% vs. -4.0%±2.9%; P=0.002); in 6MWD (33.0±19.0 vs. 12.0±6.3 metres; P=0.001); and in SGRQ (-15.0±2.9 vs. -8.0±3.5 points; P=0.01). Only patients with TLVR ≥350 mL met or exceeded the MCID cut-off criteria for FEV₁ (19.0%±3.9%), RV (-10.0%±4.8%), 6MWT (33.0±19.0 metres), and SGQR (-15.0±2.9 points). Five patients (1.2%) died during follow-up for causes not related to valves treatment neither to any of the complications described.

Conclusions: Valve treatment is a safe and reversible procedure. The presence of complications seems not to have a significant impact on clinical outcome in patients with lobar atelectasis. Due to poor clinical conditions and possible complications, BLVR should be performed in high volume centers with a multidisciplinary approach.

Keywords: Zephyr endo-bronchial valves; bronchoscopic lung volume reduction (BLVR); emphysema.

Figure 1

Small, asymptomatic pneumothorax (white arrow) (A) spontaneously resolved with clinical observation (B). Lobar atelectasis (*) of left upper lobe was preserved after resolution of pneumothorax.

Figure 2

Massive, symptomatic, pneumothorax (white arrow) (A) resolved with insertion of chest drainage (B). Lobar atelectasis (*) of left upper lobe was preserved after resolution of pneumothorax.

Figure 3

Massive, symptomatic pneumothorax following insertion of three valves in the left upper lobe (A). Pneumothorax resolved with chest drainage (B) but the persistent air-leaks required the removal of the 2th and the 3th valves (C).

Figure 4

A large valve dislocated and obstructed the main left bronchus (A). It was extracted using rigid bronchoscopy (B) restoring the air way patency (C). It was well evident the formation of granulomas due to the injury of air-way mucosa by valve. LUB, left upper bronchus; LLB, left lower bronchus.

Figure 5

Hemoptysis due to the granuloma formation (A) resolved with valve removal (B).