Endobronchial One-Way Valve Therapy Facilitates Weaning from Extracorporeal Membrane Oxygenation in a Patient with ARDS and Persistent Air Leak

Abstract

Prolonged pulmonary air leak (PAL) is a common clinical problem, associated with significant morbidity and mortality. There are numerous reports of treatment of PAL using endobronchial valves (EBV) in respiratory stable patients, but only few reports on critically ill patients, and there is virtually no practical knowledge in the treatment of PAL in mechanically ventilated patients with acute respiratory distress syndrome (ARDS), treated with veno-venous extracorporeal membrane oxygenation (vvECMO). We describe a case where EBV placement was performed in a patient with ARDS and PAL, treated with mechanical ventilation and vvECMO. Despite a lung protective ventilation strategy, a persistent air leak along with a large left-sided pneumothorax was observed. After bronchoscopic localisation of the fistula, two endobronchial valves were inserted into the left upper lobe, leading to an immediate decrease in the air flow and reexpansion of the left lung. During the following two weeks, the patient was weaned from vvECMO, and after another three weeks, complete liberation from mechanical ventilation was accomplished. EBV placement seems to be a safe method even in the presence of coagulopathy and may facilitate mechanical ventilation and weaning from vvECMO in patients with ARDS and PAL.

High incidence and mortality of pneumothorax in critically Ill patients with COVID-19

“…Protective ventilation—the prevision of P plat less than 30cmH 2 O and V T normalized to predicted body weight—reduces the alveolar pressure, overdistension alveolus, and strongly risk of pneumothorax and persistent air leak in patient s with ARDS. 27 In addition, the use of neuromuscular blockers reduces the negative pressure in pleural cavity, shear stress and changes of lung structure, and then is associated with lower incidence of pneumothorax in patients with severe ARDS (4% vs 11.7%), 15 which was also confirmed in a systematic evaluation . Cases 1 and 4 developed pneumothorax while reducing the dose of neuromuscular blocker, indicating the need of close monitor for RR, paradoxical thoracoabdominal motion or other signs of forced inhalation.…”

“…Endobronchial one-way valve facilitates the weaning process from ECMO for a patient with ARDS and persistent ail leak. 27 Case 1 encountered refractory hypoxemia and acidosis after pneumothorax and was treated by VV-ECMO. As a rescue therapy of severe ARDS and pneumothorax caused by COVID-19, VV-ECMO provides sufficient support of oxygen, allowing the lungs to rest, and earning more time for the treatment of pneumothorax and the elimination of the virus.…”

Endobronchial Valves for the Treatment of Bronchopleural Fistula and Pneumothorax Caused by Pulmonary Cryptococcosis in an AIDS Patient

“…Furthermore, EBVs can be easily removed when the air leaks are resolved to allow adequate time for tissue healing (11). We summarized the published cases using EBVs for PAL(s) in Table 1 (12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27). Only three cases were of patients with AIDS, and our case was the only patient whose SP was secondary to PC.…”

Endobronchial valves for persistent air leak all-cause mortality and financial impact: US trend from 2012–2016

“…In the US, EBVs have been used mainly for the management of post-operative PAL and, in recent years, for BLVR in emphysema, especially for patients who are high-risk surgical candidates. Occasionally, they have been used in the management of MDR-TB to help improve the effectiveness of second-line chemotherapy or to facilitate weaning from extracorporeal membrane oxygenation (ECMO) in patients with acute respiratory distress syndrome (ARDS) and PAL [6,8,9]. In Europe, they are also approved for the management of PAL in spontaneous PTX.…”