Interventional Bronchus Occlusion Using Amplatzer Devices – A Promising Treatment Option for Children with Persistent Air Leak

Abstract

Background: Persistent air leak (PAL) is a severe complication of secondary spontaneous pneumothorax (SSP). Surgical interventions are usually successful when medical treatment fails, but can be associated with significant complications and loss of potentially recoverable lung parenchyma. Methods: Retrospective analysis of efficacy and safety of interventional bronchus occlusions (IBO) using Amplatzer devices (ADs) in children with PAL secondary to SSP. Results: Six patients (four males, 4–15 years of age) underwent IBO using ADs as treatment for PAL. Necrotizing pneumonia (NP) was the most common cause (n=4) of PAL. Three patients were previously healthy and three suffered from chronic lung disease. All patients required at least two chest tubes prior to the intervention for a duration of 15–43 days and all required oxygen or higher level of ventilatory support. In three cases, previous surgical interventions had been performed without success. All children improved after endobronchial intervention and we observed no associated complications. All chest tubes were removed within 5–25 days post IBO. In patients with PAL related to NP (n=4), occluders were removed bronchoscopically without re-occurrence of pneumothorax after a mean of 70 days (IQR: 46.5–94). Conclusion: IBO using ADs is a safe and valuable treatment option in children with PAL independent of disease severity and underlying cause. A major advantage of this procedure is its less invasiveness compared to surgery and the parenchyma- preserving approach.

Zusammenfassung

Hintergrund: Die persistierende Luftleckage stellt eine schwere Komplikation eines sekundären Spontanpneumothorax (SSP) dar. Chirurgische Interventionen sind bei erfolgloser konservativer Therapie oft erfolgreich aber können mit schweren Komplikationen und dem Verlust von potentiell erholungsfähigem Lungengewebe behaftet sein. Ziel: Retrospektive Analyse über die Effektivität und Sicherheit von interventionellen Bronchus-Okklusionen (IBO) mit Amplatzer Devices (ADs) bei Kindern mit persistierender Luftleckage. Ergebnise: Bei 6 Patienten (4 männlich, Alter 4–15 Jahre) wurde eine IBO zur Therapie einer persistierenden Luftleckage durchgeführt. Die nekrotisierende Pneumonie (NP) war die häufigste zugrundeliegende Ursache einer persistierenden Leckage (n=4). 3 Kinder waren zuvor gesund, bei 3 Kindern lag eine chronische Lungenerkrankung vor. Alle Patienten benötigten vor Intervention mindestens 2 Thoraxdrainagen für 15–43 Tage und alle Kinder benötigten Sauerstoff oder eine zusätzliche Atemunterstützung. Bei 3 Patienten erfolgten zuvor erfolglose chirurgische Interventionen. Es traten keine Komplikationen im Zusammenhang mit der IBO auf. Alle Patienten profitierten von der Prozedur, die Thoraxdrainagen konnten nach 5–25 Tagen gezogen werden. Bei allen Kindern mit persistierender Luftleckage aufgrund einer NP (n=4) wurden die ADs nach durchschnittlich 70 Tagen (IQR:46.5–94) entfernt ohne dass ein Pneumothorax-Rezidiv auftrat. Schlussfolgerung: Die IBO mithilfe von ADs stellt unabhängig von der Ursache und Krankheitsschwere ein vielversprechendes und sicheres Therapieverfahren zur minimal-invasiven Behandlung von Kindern mit persistierender Luftleckage dar. Vorteile dieser Prozedur im Vergleich zu operativen Verfahren sind die geringe Invasivität und der parenchymerhaltende Ansatz.

Key words

air leak - persistent bronchopleural fistula - interventional bronchus occlusion - secondary spontaneous pneumothorax - pneumothorax - Amplatzer devices

Schlüsselwörter

Luftleckage - Persistierende bronchopleurale Fistel - interventionelle Bronchusokklusion - sekundärer Spontanpneumothorax - Pneumothorax - Amplatzer Okkluder

^*Katharina Schütz and Christoph M Happel contributed equally to the manuscript.

Publication History

Received: 31 August 2021
Received: 31 August 2021

Accepted: 15 November 2021

Article published online:
03 January 2022

• References

• 1 Dugan KC, Laxmanan B, Murgu S, Hogarth DK. Management of Persistent Air Leaks. Chest 2017; 152: 417-423
• 2 Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev 2009; 10: 110-117 quiz 117
• 3 Sawicki GS, Lu FL, Valim C, Cleveland RH, Colin AA. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur Respir J 2008; 31: 1285-1291
• 4 Kagan S, Nahum E, Kaplan E, Kadmon G, Gendler Y, Weissbach A. Persistent pulmonary air leak in the pediatric intensive care unit: Characteristics and outcomes. Pediatr Pulmonol 2021; 56: 2729-2735
• 5 McKee AJ, Ives A, Balfour-Lynn IM. Increased incidence of bronchopulmonary fistulas complicating pediatric pneumonia. Pediatr Pulmonol 2011; 46: 717-721
• 6 Sakata KK, Reisenauer JS, Kern RM, Mullon JJ. Persistent air leak – review. Respir Med 2018; 137: 213-218
• 7 Liberman M, Muzikansky A, Wright CD, Wain JC, Donahue DM, Allan JS. et al. Incidence and risk factors of persistent air leak after major pulmonary resection and use of chemical pleurodesis. Ann Thorac Surg 2010; 89: 891-897 discussion 897-8
• 8 Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management. Ann Thorac Cardiovasc Surg 2001; 7: 330-336
• 9 Sonobe M, Nakagawa M, Ichinose M, Ikegami N, Nagasawa M, Shindo T. Analysis of risk factors in bronchopleural fistula after pulmonary resection for primary lung cancer. Eur J Cardiothorac Surg 2000; 18: 519-523
• 10 MacDuff A, Arnold A, Harvey J, Pleural BTS. DiseGuideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 ii 18-31
• 11 Robinson PD, Cooper P, Ranganathan SC. Evidence-based management of paediatric primary spontaneous pneumothorax. Paediatr Respir Rev 2009; 10: 110-117 quiz 117
• 12 Jaspers GJ, Willemse BWM, Kneyber MCJ. Endobronchial valve placement for a severe pneumothorax in a child on ECLS. Pediatr Pulmonol 2019; 54: 1875-1877
• 13 Chambers A, Routledge T, Bille A, Scarci M. Is blood pleurodesis effective for determining the cessation of persistent air leak?. Interact Cardiovasc Thorac Surg 2010; 11: 468-472
• 14 Heffner JE, Standerfer RJ, Torstveit J, Unruh L. Clinical efficacy of doxycycline for pleurodesis. Chest 1994; 105: 1743-1747
• 15 Lang-Lazdunski L, Coonar AS. A prospective study of autologous 'blood patch' pleurodesis for persistent air leak after pulmonary resection. Eur J Cardiothorac Surg 2004; 26: 897-900
• 16 Manley K, Coonar A, Wells F, Scarci M. Blood patch for persistent air leak: a review of the current literature. Curr Opin Pulm Med 2012; 18: 333-338
• 17 Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J. et al. Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement. Chest 2001; 119: 590-602
• 18 MacDuff A, Arnold A, Harvey J, Pleural BTS. DiseGuideline Group. Management of spontaneous pneumothorax: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65 ii 18-31
• 19 Schweigert M, Dubecz A, Beron M, Ofner D, Stein HJ. Surgical therapy for necrotizing pneumonia and lung gangrene. Thorac Cardiovasc Surg 2013; 61: 636-641
• 20 Akulian J, Pathak V, Lessne M, Hong K, Feller-Kopman D, Lee H. et al. A novel approach to endobronchial closure of a bronchial pleural fistula. Ann Thorac Surg 2014; 98: 697-699
• 21 Toth JW, Podany AB, Reed MF, Rocourt DV, Gilbert CR, Santos MC. et al. Endobronchial occlusion with one-way endobronchial valves: a novel technique for persistent air leaks in children. J Pediatr Surg 2015; 50: 82-85
• 22 Criss CN, Barbaro R, Bauman KA, Folafoluwa O, Vellody R, Jarboe MD. Selective Management of Multiple Bronchopleural Fistulae in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach. J Laparoendosc Adv Surg Tech A 2018; 28: 1271-1274
• 23 Klotz LV, Gesierich W, Schott-Hildebrand S, Hatz RA, Lindner M. Endobronchial closure of bronchopleural fistula using Amplatzer device. J Thorac Dis 2015; 7: 1478-1482
• 24 Gomez Lopez A, Garcia Lujan R. AD -artment of Respiratory Medicine, University Hospital 12 de Octubre, Madrid,,Spain., De Pablo Gafas A, Hernandez Hernandez F, Villena Garrido V, Valipour A, et al. First use of Amplatzer device for bronchopleural fistula after lung transplantation. Thorax 2017; 72: 668-670
• 25 Fruchter O, Kramer MR, Dagan T, Raviv Y, Abdel-Rahman N, Saute M. et al. Endobronchial closure of bronchopleural fistulae using amplatzer devices: our experience and literature review. Chest 2011; 139: 682-687
• 26 Fruchter O, El Raouf BA, Abdel-Rahman N, Saute M, Bruckheimer E, Kramer MR. Efficacy of bronchoscopic closure of a bronchopleural fistula with amplatzer devices: long-term follow-up. Respiration 2014; 87: 227-233
• 27 Papiashvilli M, Bar I, Sasson L, Priel IE. Endobronchial closure of recurrent bronchopleural and tracheopleural fistulae by two amplatzer devices. Heart Lung Circ 2013; 22: 959-961
• 28 Lois M, Noppen M. Bronchopleural fistulas: an overview of the problem with special focus on endoscopic management. Chest 2005; 128: 3955-3965
• 29 Lazarus DR, Casal RF. Persistent air leaks: a review with an emphasis on bronchoscopic management. J Thorac Dis 2017; 9: 4660-4670
• 30 Gilbert CR, Casal RF, Lee HJ, Feller-Kopman D, Frimpong B, Dincer HE. et al. Use of One-Way Intrabronchial Valves in Air Leak Management After Tube Thoracostomy Drainage. Ann Thorac Surg 2016; 101: 1891-1896
• 31 Travaline JM, McKenna RJ, De Giacomo T, Venuta F, Hazelrigg SR, Boomer M. et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009; 136: 355-360