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

2. 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

3. 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

4. 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

5. 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

6. 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.

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

8. 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

9. 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.