Endobronchial valve for the treatment of Bronchopleural fistula (BPF) R4 SEON HYE KIM/Prof. MYUNG JAE PARK

INTRODUCTION Bronchopleural fistula (BPF) Definition : a communication between the pleural space and the bronchial tree ( main stem, lobar, and segmental bronchus) Prolonged hospital stay & significant morbidity and mortality No standard treatment guidelines Etiology 1> post-operative 2> non-operative necrotising pneumonia/empyema lung neoplasms, blunt and penetrating lung injuries complication of procedures: lung biopsy, chest tube drainage, thoracocentesis radiation therapy

INTRODUCTION Incidence of BPF following lung resection in pts w/ lung cancer  approximately 2 to 6% (1.5~28% after pulmonary resection) Risk factors the presence of a long & large bronchial stump carcinoma at the bronchial margin preexistent empyema or other pleural/pulmonary infection mechanical ventilation preoperative chemotherapy or radiation therapy. current or former smoking, male gender diabetic mellitus, hypoalbuminemia Complication aspiration pneumonia and subsequent acute respiratory distress syndrome tension pneumothorax

CLINICAL MANIFESTATIONS BPF can be a life-threatening condition d/t tension pneumothorax or asphyxiation from pulmonary flooding. sudden appearance of dyspnea, hypotension, subcutaneous emphysema cough with expectoration of purulent material or fluid shifting of the trachea and mediastinum, persistence of air leak fibrosis of the pleural space and mediastinum

DIAGNOSIS Diagnosis and localization of BPF is sometimes difficult and may require multiple imaging and bronchoscopies. Bronchoscopic exploration direct visualization of the fistula : continuous air bubbles instillation of methylene blue through the stump and its detection in the chest tube guidance of a balloon-tipped catheter into the selected airways and inflation of the balloon injection of small boluses of 133Xe into bronchi looking for radioactivity in the chest tube Chest CT etiology, pneumothorax or surgical intervention Scintigraphy

TREATMENT AND MANAGEMENT Percutaneous Drainage Primary goals of BPF management treating the underlying lung disease reducing the air leak by adequate drainage Infectious etiologies are present or empyema is suspected, adequate drainage of the pleural space is mandatory along with proper antimicrobial coverage. preventing pleural sepsis and aspiration pneumonia remain essential to the initial management of these patients.

TREATMENT AND MANAGEMENT Surgery Ix: >5mm, large BPF Surgical repair with muscle-flap closure Completion lobectomy/pneumonectomy

TREATMENT AND MANAGEMENT Bronchoscopic closure Ix: <5mm, small BPF, poor surgical candidates Minimally invasive Multiple sealing compounds have been applied directly to the fistula through the bronchoscope Sealents: gel foam, fibrin glue, methylmethacrylate absolute ethanol endobronchial silicone plugs albumin gluteraldehyde tissue adhesive decalcified bone, and lead plugs balloon catheter occlusions coiling Limitation : low likelihood of success, dependent on endoscopiest

TREATMENT AND MANAGEMENT Endobronchial valve (one-way) Unique method of BPF closure using an endobronchial valve that was designed for the palliative treatment of emphysema The valve is made of a central silicone core that is fashioned to drain air and secretions from the distal lung segment, while blocking entry of air, resulting in redirection of airflow away from diseased segments and, in some cases, collapse of the diseased segment and expansion of the more normal adjacent lung. The core is surrounded by a nitinol expandable mesh that anchors the valve within the bronchus. The valve is inserted through the working channel of the bronchoscope using a guided insertion device provided by the manufacturer.

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