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 outcome 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 (FEV 1); 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 FEV 1 (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 cutoff criteria for FEV 1 (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.

Endobronchial valve placement for a severe pneumothorax in a child on ECLS

“…2 Though results are promising, there is much that remains unanswered. In adults, complications of, for example, migration, pneumonia, and hemoptysis have been reported, 5 but in children, the risks are unknown. Though minimally invasive, both flexible bronchoscopy and placing the EBV carry a risk of bleeding in patients on ECLS.…”

Combined intrapleural and intrabronchial injection of fibrin glue for closing alveolar pleural fistula: a case report

“…Despite we used the largest valve commercially available (5.5 Zephyr EBV), probably it was too small for the size of the RB9 segment. Yet, the loss of elastic recoil related to underlying COPD increased the risk of dislocation [4]. Second, we closed the RB9 segment with FG [2, 3], but also this procedure failed as fibrin clot dislocated probably due to frequent airway aspirations.…”

Endobronchial valve therapy for severe emphysema: an overview of valve-related complications and its management

“…These problems have been described after surgical lobectomy, and mainly after treatment of the upper lobes [27,28]. The occurrence of bronchial angulation after valve treatment has been reported in less than 5% of treated patients [29][30][31]. The clinical presentation may be relatively mild, but due to the narrowing or folding of airways there may be complaints of dyspnea caused by a ventilation/perfusion mismatch and mucus retention with persistent cough (Figure 2).…”

“…The extent of the valve migration is most often limited to minor changes in the original position; however, sometimes the valves may migrate to the ipsilateral lobe(s), the contralateral lung or be expectorated. Clinical signs that are suggestive of valve migration are sudden loss of beneficial effect, increased coughing and sudden chest discomfort [12,29]. Also, the history may reveal a whistling sound on inspiration [39].…”