Successful use of endobronchial valve for persistent air leak in a patient with COVID-19 and bullous emphysema

Persistent air leak secondary to pneumothorax in COVID-19: A case report and review of literature

An air leak is a pathologic communication between an area of the endobronchial tree and the pleural space, causing continued air flow. The communication can originate from a distal portion of the airway, causing an alveolar-pleural fistula, or from a more proximal airway, causing a bronchopleural fistula. When the air leak persists beyond 5-7 days, it is classified as persistent air leak (PAL). PAL has serious implications on patient management and outcomes, such as prolonged chest tube maintenance, high rate of infections, ventilation-perfusion mismatch, and prolonged hospital stay with higher morbidity and mortality. There are currently no guidelines for the management of PAL in COVID-19 patients. We presented a case of PAL in a patient with COVID-19-associated pneumothorax successfully treated with a one-way endobronchial valve. We also reviewed current published cases of PAL secondary to COVID-19-associated pneumothorax and the various methods they were treated. The first line treatment was insertion of one or more chest tubes, but the persistence of an air leak then led to other treatment modalities. Initial early surgical evaluation followed by pleurodesis is recommended for the management of PAL. The most common surgical approaches include VATS or open thoracotomy with mechanical or chemical pleurodesis or pleurectomy. However, surgery is not always a feasible option for critically ill patients. In such cases, there are multiple less invasive options for the management of PAL, including implantable devices, such as Watanabe spigots and stents, and chemical agents, such as thermal treatments, hemostatic substances, and tissue adhesives.

Hypoxemia After Endobronchial Valve Deployment for Persistent Air Leak

Endobronchial valves (EBVs) are a novel, minimally invasive bronchoscopic management technique for persistent air leaks that fail conservative therapy. Currently, 2 EBVs are available in the United States: the Spiration Valve System (Olympus, Redmond, WA) and the Zephyr Valve (Pulmonx, Redwood, CA). These valves are Food and Drug Administration-approved to reduce hyperinflation in emphysematous patients via bronchoscopic lung-volume reduction. However, more recently, the Spiration Valve has been granted a compassionate use exemption through the Food and Drug Administration for persistent postsurgical air leaks. Despite their popularity, these devices are not free from side effects. As an anesthesiologist, it is vital to be aware of the pathophysiology of this patient population so that safe and effective anesthetics may be provided during valve placement. Here, the use of EBVs is discussed in a patient who presented with a persistent air leak after a transthoracic needle aspiration that failed treatment due to persistent hypoxemia, warranting EBV removal.

Prognosis of Spontaneous Pneumothorax/Pneumomediastinum in Coronavirus Disease 2019: The CoBiF Score

Objectives: Pneumothorax and pneumomediastinum are associated with high mortality in invasively ventilated coronavirus disease 2019 (COVID-19) patients; however, the mortality rates among non-intubated patients remain unknown. We aimed to analyze the clinical features of COVID-19-associated pneumothorax/pneumomediastinum in non-intubated patients and identify risk factors for mortality. Methods: We searched PubMed Scopus and Embase from January 2020 to December 2021. We performed a pooled analysis of 151 patients with no invasive mechanical ventilation history from 17 case series and 87 case reports. Subsequently, we developed a novel scoring system to predict in-hospital mortality; the system was further validated in multinational cohorts from ten countries (n = 133). Results: Clinical scenarios included pneumothorax/pneumomediastinum at presentation (n = 68), pneumothorax/pneumomediastinum onset during hospitalization (n = 65), and pneumothorax/pneumomediastinum development after recent COVID-19 treatment (n = 18). Significant differences were not observed in clinical outcomes between patients with pneumomediastinum and pneumothorax (±pneumomediastinum). The overall mortality rate of pneumothorax/pneumomediastinum was 23.2%. Risk factor analysis revealed that comorbidities bilateral pneumothorax and fever at pneumothorax/pneumomediastinum presentation were predictors for mortality. In the new scoring system, i.e., the CoBiF system, the area under the curve which was used to assess the predictability of mortality was 0.887. External validation results were also promising (area under the curve: 0.709). Conclusions: The presence of comorbidity bilateral pneumothorax and fever on presentation are significantly associated with poor prognosis in COVID-19 patients with spontaneous pneumothorax/pneumomediastinum. The CoBiF score can predict mortality in clinical settings as well as simplify the identification and appropriate management of patients at high risk.

Air leaks in COVID-19

Coronavirus disease 2019 (COVID-19) continues to create havoc and may present with myriad complications involving many organ systems. However, the respiratory system bears the maximum brunt of the disease and continues to be most commonly affected. There is a high incidence of air leaks in patients with COVID-19, leading to acute worsening of clinical condition. The air leaks may develop independently of the severity of disease or positive pressure ventilation and even in the absence of any traditional risk factors like smoking and un-derlying lung disease. The exact pathophysiology of air leaks with COVID-19 remains unclear, but multiple factors may play a role in their development. A significant proportion of air leaks may be asymptomatic; hence, a high index of suspicion should be exercised for enabling early diagnosis to prevent further deterioration as it is associated with high morbidity and mortality. These air leaks may even develop weeks to months after the disease onset, leading to acute deterioration in the post-COVID period. Conservative management with close monitoring may suffice for many patients but most of the patients with pneumothorax may require intercostal drainage with only a few requiring surgical interventions for persistent air leaks.

Bronchopleural Fistula and Endobronchial Valve Placement in a Patient With COVID-19 Pneumonia: A Case Report With Literature Review

Bronchopleural fistulas (BPFs) are associated with high morbidity and mortality. Though most commonly seen after surgical interventions, they are increasingly reported as complications of COVID-19 infection. We present the case of an 86-year-old man with COVID-19 pneumonia and subsequent bronchopleural fistula (BPF) with persistent air leak. Endobronchial valves were placed in apical and posterior segments of the right upper lobe resulting in successful cessation of the air leak. The purpose of the case report and literature review is to help guide the management of persistent air leak.