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Bronchoscopic lung volume reduction surgery (BLVRS) is a minimally invasive treatment option for severe emphysema with hyperinflation and air trapping. The one-way valves are designed to induce lobar atelectasis. The most common complication is pneumothorax, which usually develops within 72 hours after BLVRS. We present a case of delayed atelectasis with a large left pneumothorax, 3 years after left upper lobe (LUL) BLVRS with three ZypherÒ valves. CASE PRESENTATION:A 64 year-old-female with a past medical history of severe emphysema on oxygen presented to a local hospital with dyspnea. Chest radiography revealed a large left pneumothorax. CT chest also showed complete LUL atelectasis. Of note in 2018, the patient underwent LUL BLVRS without interval development of atelectasis. Given the new findings, a chest tube was placed. She was transferred to our hospital for interventional pulmonary consultation after 6 days of conservative management for persistent air leak. Bronchoscopy revealed three ZypherÒ valves occluding the LUL and lingula. Balloon occlusion of the left main stem resulted in air leak cessation. Subsegmental occlusion of the left lower lobe superior segment revealed no change, but there was significant air leak reduction after anteromedial segment occlusion. A 5 mm SpirationÒ valve was then deployed, causing the air leak in the pleurovac to switch from continuous to intermittent. Over the next 48 hours, the air leak resolved with near resolution of the pneumothorax. Chest tube was removed, and the patient was discharged home after 24 hour observation.

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