Expert Statement: Pneumothorax Associated with One-Way Valve Therapy for Emphysema: 2020 Update

Abstract

For selected patients with advanced emphysema, bronchoscopic lung volume reduction with one-way valves can lead to clinically relevant improvements of airflow obstruction, hyperinflation, exercise capacity, and quality of life. The most common complication of this procedure is pneumothorax with a prevalence of up to ±34% of the treated patients. Patients who develop a pneumothorax also experience meaningful clinical benefits once the pneumothorax is resolved. Timely resolution of a post-valve treatment pneumothorax requires skilled and adequate pneumothorax management. This expert panel statement is an updated recommendation of the 2014 statement developed to help guide pneumothorax management after valve placement. Additionally, mechanisms for pneumothorax development, risk assessment, prevention of pneumothorax, and outcomes after pneumothorax are addressed. This recommendation is based on a combination of the current scientific literature and expert opinion, which was obtained through a modified Delphi method.

Complications of Endobronchial Valve Placement for Bronchoscopic Lung Volume Reduction

“…The alternatives found in our analysis are consistent with the most recent expert statement update in 2021. 25 Other methods mentioned but were not demonstrated in our study are upsizing the initial pleural catheter, mechanical or chemical pleurodesis, and consideration for surgery. The choice of therapeutic approach is mainly dependent on the clinical stability of the patient, patient preference, the experience and availability of each modality in each institution where the BLVR with EBV placement was performed.…”

“…The increase was attributed to better patient selection, especially in evaluating the absence of collateral ventilation using the Chartis system during bronchoscopy. 25 These findings are informative since further studies can be performed to isolate the specific risks and study methods to reduce the risks. For example, the presence of pleural adhesion in the target lung, the presence of paraseptal emphysema, and significant volume differences between the target lobe and ipsilateral lobe(s) have been thought to increase the risk of pneumothorax post-BLVR.…”

Bronchoscopic Lung Volume Reduction for Emphysema: Review and Update

“…Possible risk factors for developing a pneumothorax are pleural adhesions, paraseptal emphysema, volume disbalance of the target lobe and the ipsilateral lobe and high emphysematous destruction of the ipsilateral lobe. 22,43 Adequate pneumothorax management is essential and may be complicated. Management recommendations and proposed timelines are described in the recently published expert statement by van Dijk et al 22 Later onset complications include granulation tissue formation, which can lead to valve dysfunction, hemoptysis, infectious complications, and cough.…”

Long-Term Follow-Up of Intralobar Bullae After Endobronchial Valve Treatment for Emphysema

“…Additionally, the occurrence of pneumothorax, which is the most frequent adverse event following EBV placement, was found in 4.2–34.4% of the treated patients. 3 Because the ipsilateral lobe rapidly expands into the space created in the pleural cavity by atelectasis of the target lobe, some blebs or bullae from the ipsilateral lobe could break up, especially in the presence of pleural adhesions. 3 , 4 Some risk factors were reported in association with a higher rate of pneumothorax such as a high percentage of low attenuation volume of the untreated ipsilateral lobe and a high residual volume.…”

“… 3 Because the ipsilateral lobe rapidly expands into the space created in the pleural cavity by atelectasis of the target lobe, some blebs or bullae from the ipsilateral lobe could break up, especially in the presence of pleural adhesions. 3 , 4 Some risk factors were reported in association with a higher rate of pneumothorax such as a high percentage of low attenuation volume of the untreated ipsilateral lobe and a high residual volume. However, a high ratio of the untreated ipsilateral lobe volume compared to the volume of the hemithorax and panlobular emphysema was found to be protective.…”