Use of Endobronchial Valve to Treat COVID-19 Adult Respiratory Distress Syndrome Related Alveolopleural Fistula

Abstract

Introduction: Coronavirus Disease 2019 (COVID 19) is a viral illness caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2). We report a patient with COVID-19 pneumonia leading to ARDS and subsequent development of an alveolopleural fistula who was successfully treated with multiple endobronchial valves. Case: The Patient was a 55-year-old Hispanic male who presented with 2 days of dry cough and shortness of breath. Vital signs on admission showed an oxygen saturation of 68% on ambient air and respiratory rate of 30 breaths per minute. He was admitted with acute hypoxic respiratory failure and found to have a positive SARS-Cov2 infection. Initial CT chest without contrast showed diffuse bilateral ground-glass opacities. His oxygen requirement increased as well as his work of breathing requiring BiPAP, and subsequent intubation. On the 10th day of admission, he developed a right-sided pneumothorax, requiring chest tube placement. A tracheostomy was completed on day 14 for further ventilator weaning. On day 20, he developed persistent air leak concerning for an alveolopleural fistula, repeat CT chest concerning for a moderate-sized pneumothorax and findings concerning for post ARDS fibrotic lungs. He continued to have persistent air leak but was not deemed to be a surgical candidate hence he was referred for endobronchial valve placement to facilitate chest tube removal and ventilator weaning. Bronchoscopy was done on day 41 of admission. Total 6 endobronchial valves were placed (right middle and lower lobes). Over next few days his leak completely resolved. Patient was weaned off of positive pressure a week later to trach collar, and the chest tube was subsequently removed. Discussion: Alveolopleural fistula is a communication or fistula between a alveoli and the pleural space. Patient's with ARDS secondary to COVID-19 requiring high amounts of PEEP and are at higher risk in developing a pneumothorax. Endobronchial valves (EBV) have been used since 2005 to treat alveolopleural and bronchopleural fistula in patients who are not considered a good surgical candidate. This is the first documented use of an EBV in the setting of COVID-19 that we could find. The placement of the valves, allowed a significant reduction in the air leak. This assisted in the patient's breathing trials on the ventilator and tracheostomy collar trials by reducing the overall volume loss through the fistula, ultimately allowing the patient to successfully liberated from the ventilator and have his chest tubes removed.

SARS Cov-2 Infection-Related Persistent Air Leaks Managed By Endobronchial Valves

“…We report two of the first few cases of COVID-19 complicated by PALs that were successfully managed with Endobronchial Valve placement. Our data search reveals six reported cases of COVID-19 that eventually developed PAL and managed with the placement of EBV and resulted in the successful resolution of the air leak [8,12,[15][16][17]. The ages of the cases in the patient group ranged from 42 to 73 years old.…”

“…This prevents entry of air distal to the valve causing segmental atelectasis and resolution of pneumothorax. Reduced airflow across the fistula allows healing of the abnormal fistulous tract [16]. EBV is the best procedure to manage PALs when surgical options are not feasible or anatomically impossible.…”