Endobronchial Valve Insertion for the Management of Persistent Air Leak Following Pneumothorax

Persistent air leak following a pneumothorax refers to air leakage lasting 5-7 days after the initial event. Different strategies have been used with varying degrees of success including surgical or chemical pleurodesis. Endobronchial valve (EBV) insertion is a technique where the insertion of a one-way valve obstructs the flow of air through the leak and helps in pneumothorax resolution especially if surgery is contraindicated. We present the case of a gentleman in his 60s who was admitted with a right-sided pneumothorax on the background of grade 4 glioblastoma. A 12-French chest drain was inserted for the management of his pneumothorax. A CT scan was requested due to failure of resolution of pneumothorax at five days post chest drain insertion, evidenced by ongoing bubbling in the underwater seal. CT revealed moderate right-sided pneumothorax and a possible bronchopleural fistula arising from the right upper lobe posterior segment bronchiole. He was unfit for surgery. A second chest drain was inserted but the air leak did not settle. It was then decided to insert EBV using bronchoscopy under sedation and Zephyr valves were used for this procedure. Balloon blockage of the right upper lobe led to the disappearance of air leak in the underwater seal on -5 kPa suction whereas blocking individual branches did not lead to the termination of air leak, therefore, it was decided to insert valves on all the segments of the right upper lobe. Four days after the EBV insertion his air leak resolved and his chest X-ray (CXR) showed a resolution of pneumothorax, so his chest drain was removed. He was subsequently discharged home. EBV insertion can facilitate pneumothorax resolution and discharge in carefully selected patients and should be used with a multi-disciplinary approach. In our case, this approach helped to facilitate the transfer of a terminally ill patient to his preferred place of comfort.